UNIVERSITY  of 

AT 

LOS  ANGELES 
LIBRARY 


FHONT  VIEW  or  THE  ORGANS  IN  THEIR  NATURAL  RELATIONS. 
The  heart  Is  partly  covered  by  the  lungs,  but  its  true  outline  is  indicated 
by  a  dotted  line.    Only  ten  ribs  are  shown  on  each  side,  the  eleventh 
and  twelfth  (the  floating  ribs)  being  too  short  to  be  included  in  the 
section. 


A   TEXT-BOOK   OF 

NURSING 


FOR    THE    USE    OF    TRAINING    SCHOOLS,    FAMILIES, 
/IND  PRIVATE  STUDENTS 


BY 

CLARA   WEEKS-SHAW 


/  *  7  S  1 

THIRD  EDITION,  THOROUGHLY  REVISED 
AND   ENLARGED 


NEW    YORK 

D.   APPLETON    AND     COMPANY 
i  906 

IG751 
NUV  ISO/ 


COPYRIGHT,  1885,  1892,  1902 
BY  D.   APPLETON  AND   COMPANY 


S53  t 


THE  holiest  task  by  Heaven  decreed, 

An  errand  all  divine, 
The  burden  of  our  common  need 

To  render  less,  is  thine. 

The  paths  of  pain  are  thine.     Go  forth 
With  patience,  trust,  and  hope  ; 

The  sufferings  of  a  sin-sick  earth 
Shall  give  thee  ample  scope. 

Beside  the  unveiled  mysteries 

Of  life  and  death  go  stand, 
With  guarded  lips  and  reverent  eyes, 

And  pure  of  heart  and  hand. 

J.  Or.  WHITTIER. 


PEEFACE  TO   THE  THIKD  EDITION 


THIS  book,  first  introduced  to  the  public  by  my 
ever-to-be-remembered  friend,  Prof.  Edward  L.  You- 
mans,  to  whose  most  kind  encouragement  and  assist- 
ance it  owed  its  existence,  is  now  for  the  second  time 
revised  and  brought  up  to  date  under  the  supervision 
of  his  niece,  Dr.  Alice  C.  Youmans.  It  follows  the 
same  practical  lines  as  the  earlier  editions,  and  until 
something  more  comprehensive  is  offered,  I  trust  will 
continue  to  be  of  use  to  nurses  both  amateur  and  pro- 
fessional. Primarily  designed  for  the  latter  class,  I 
assume  that  elementary  acquaintance  with  anatomy  and 
physiology  which  is  now  of  course  a  fundamental  part 
of  their  training.  The  fragments  of  these  here  intro~ 
duced,  serving  for  them  merely  the  purpose  of  review, 
may  perhaps  render  the  context  more  intelligible  to  the 
untrained  majority  whom  also  I  hope  to  help.  To  the 
whole  nursing  sisterhood,  I  present  it,  in  memory  of  the 
days  when  I  was  one  of  them,  adding  a  reminder  that 
"  they  never  are  alone  who  are  accompanied  by  noble 
thoughts." 

CLABA  W.  SHAW. 

1908. 


CONTENTS 


CHAPTER  PA  Oft 

I.  INTRODUCTORY — NURSING  AND  NURSES     ...  1 

II.  THE  SICK-ROOM — THE  HOSPITAL  WARD     ...  14 

III.  BEDS  AND  BED-MAKING — BED-SORES  ....  28 

IV.  CIRCULATION — PULSE — TEMPERATURE       ...  44 
V.  RESPIRATION — VENTILATION — WARMTH    ...  62 

VI.  THE  SKIN — BATHS — MASSAGE 75 

VII.  URINE — CATHETERIZATION — ENEMATA       ...  90 

VIII.  THE  OBSERVATION   OF   SYMPTOMS           ....  110 

IX.  MEDICINES  AND  THEIR  ADMINISTRATION    .       .       .  125 

X.  LOCAL  APPLICATIONS — VENESECTION— TRANSFUSION  .  154 

XL  FOOD  AND   ITS   ADMINISTRATION 172 

XII.  BONES — FRACTURES — DISLOCATIONS— BANDAGING     .  194 

XIII.  CONTAGION  AND  DISINFECTION 223 

XIV.  SURGICAL  NURSING — OPERATION  CASES     .        .        .  234 
XV.  GYN^ICOLOGY 260 

XVI.  OBSTETRICS 268 

XVII.  SICK  CHILDREN 289 

XVIII.  SPECIAL  MEDICAL  CASES 306 

XIX.  EMERGENCIES,  SURGICAL  AND  MEDICAL     .       .       .  335 

XX.  THE  TERMINATIONS  OF  DISEASE         ....  371 

VOCABULARY      .       . 379 

INDEX  .                                                                    ,  393 


TEXT-BOOK   OF  NURSING 

It,  7S/ 

CHAPTER   I 

"Blessed  is  he  who  has  found  his  work;  let  him  ask  no  other 
blessedness." — T.  Carlyle. 

HEALTH  has  been  comprehensively  defined  as  the 
"perfect  circulation  of  pure  blood  in  a  sound  organ- 
ism."   Any  departure  from  either  of  these  three  condi- 
tions constitutes  disease.    There  is  recognized  in  nature 
a  certain  tendency  to  reparation,  a  predisposition  to  re- 
turn to  the  conditions  of  health,  whenever  there  has 
been  any  deviation  from  them.    To  assist  this  is  the  ob- 
ject of  treatment.     To  keep  the  patient  in  the  state 
i     most  favorable  for  the  action  of  this  reparative  tend- 
-    ency,  is  especially  the  vocation  of  the  nurse.     There 
^    are  few  who  will  not  be  called  upon  to  serve  in  this 
^  capacity  at  some  time  in  their  lives;  fewer  still  who 
^   will  not  at  some  time  have  occasion  to  be  grateful  for 
the  ministrations  of  a  skill'iu  and  efficient  nurse,  or 
annoyed  by  the  blunders  of  an  awkward  and  incom- 
petent one. 

Nursing,  therefore,  is  an  art,  the  importance  of 
which  can  scarcely  be  overestimated.  It  properly  in- 
cludes, as  well  as  the  execution  of  specific  orders,  the 
administration  of  food  a  ad  medicine,  the  personal  care 
of  the  patient,  attention  to  the  condition  of  the  sick- 
room, its  warmth,  cleanliness,  and  ventilation,  the  care- 

1 


2  A  TEXT-BOOK  OF  NURSING 

f ul  observation  and  reporting  of  symptoms,  and  the  pre- 
vention of  contagion.  It  is  a  work  which  falls  largely, 
though  not  exclusively,  to  the  share  of  women,  and  it 
has  sometimes  been  claimed  that  all  women  make  good 
nurses  simply  by  virtue  of  their  womanhood.  But  this 
is  far  from  true.  To  fitly  fill  such  a  position  requires 
certain  physical  and  mental  attributes,  which  all  women 
— even  all  good  women — do  not  possess,  as  well  as  some 
special  training.  A  natural  aptitude  for  nursing  is  a 
valuable  basis  for  instruction,  but  will  not  take  the  place 
of  it,  nor  will  good  intentions  ever  compensate  for  a 
lack  of  executive  ability. 

Unimpaired  health  and  power  of  endurance,  intelli- 
gence and  common  sense,  are  primary  essentials  for  a 
nurse.  She  should  be  a  person  of  even,  cheerful  tem- 
perament, not  easily  irritated  or  confused — for  to  lose 
temper  or  presence  of  mind  in  the  sick-room  ig  fatal  to 
usefulness.  She  must  have  acute  perceptions,  habits  of 
correct  observation  and  accurate  statement,  and  some 
manual  dexterity.  She  needs  to  be  quiet,  neat,  and  sys- 
tematic, and  capable  of  eternal  vigilance. 

There  is  in  this  work,  room  for  the  exercise  of  tal- 
ents of  the  highest  and  virtues  of  the  rarest  order;  and 
it  ought  not  to  be  true,  as  it  is,  that  many  of  the 
applications  for  admission  into  our  training-schools  are 
from  those  utterly  unfit  for  the  work;  either  surviving 
relics  of  the  by-gone  times -when  a  nurse  ranked  on  or 
below  the  par  of  house-ma'd,  or  sentimentalists  with 
their  heads  full  of  romantic  visions  of  themselves  flit- 
ting about  like  angels  of  mercy,  bathing  the  brows  of 
suffering  heroes,  and  distributing  among  them  flowers 
and  smiles.  The  latter  class  arc  sure  to  be  disappointed, 
generally  disgusted,  for  they  fir.d  the  reality  practical, 
prosaic,  and  often  even  revolting.  But  it  is  a  field  of 


INTRODUCTORY— NURSING  AND  NURSES          3 

usefulness  such  as  is  nowhere  else  afforded,  and  a  woman 
with  the  requisite  qualifications,  who  desires  to  be  really 
of  service  to  her  fellow-creatures,  and  to  adopt  an  em- 
ployment of  absorbing  interest,  can  not  do  better  than 
to  train  herself  for  a  nurse.  It  is  to  such  as  have  en- 
tered upon  this  course  with  an  earnest  aim  to  well 
qualify  themselves,  and  to  elevate  the  professional 
standard,  that  the  following  instructions  are  addressed./' 

When  you  have  once  undertaken  the  care  of  a  sick 
person,  his  welfare  is  of  course  understood  to  become 
your  first  consideration.  With  this  object  always  in 
view,  your  duties  may  be  classified  as  threefold:  those 
which  you  owe  to  yourself,  those  due  to  the  physician 
under  whose  direction  you  work,  and  such  as  relate  im- 
mediately to  the  patient.  Something  is  perhaps  owing 
also  to  the  school  with  which  you  are  or  have  been  con- 
nected. You  are  at  least  afforded  an  additional  motive 
for  guarded  conduct  by  the  remembrance  that  you  are 
its  representative  to  the  public,  the  exponent  of  its 
methods,  and  that,  according  as  you  behave  yourself 
well  or  ill,  credit  or  discredit  is  reflected  upon  the  en- 
tire school.  It  may  at  first  glance  seem  somewhat 
strange  to  assert  that  your  own  personal  duties  should 
take  precedence,  but  a  little  reflection  will  show  that 
whatever  theories  of  self-devotion  you  may  entertain, 
and  however  willing  you  may  be  to  sacrifice  your  own 
comfort  to  the  welfare  of  your  patient,  disregard  of  the 
duties  to  yourself  will  sooner  or  later  incapacitate  you 
for  the  fulfillment  of  all  others.  You  may  give  up  your 
convenience,  your  pleasure — indeed  will  be  perpetually 
called  upon  to  do  so  as  the  inevitable  claim  of  the  work 
you  have  chosen — but  your  health  you  have  no  right  to 
risk.  Remember  that  self-sacrifice  is  not  always  unsel- 
fishness, and  that  the  nurse  who  takes  the  best  care  of 


4  A  TEXT-BOOK  OF  NURSING 

her  own  health  will  be  beet  able  to  care  for  her  patient. 
Ill-regulated  zeal  only  defeats  its  own  object;  if  you 
wish  to  be  really  and  permanently  efficient,  you  will  take 
pains  not  to  lower  the  standard  of  your  own  physical 
condition.  Even  a  nurse  is  but  human;  you  can  not 
retain  your  vigor  and  consequent  usefulness  without  a 
due  allowance  of  rest,  food,  and  exercise.  It  is  your 
duty,  as  well  as  your  right,  to  insist  upon  securing  these, 
and  to  take  proper  time  for  the  care  of  your  own  person, 
and  for  your  meals.  You  owe  it  to  yourself  also,  and  to 
the  whole  nursing  sisterhood,  to  enforce  a  suitable  re- 
gard for  your  reputation,  and  for  the  dignity  of  your 
position.  The  maintenance  of  strict  propriety  and  de- 
corum on  your  own  part  will  rarely  fail  to  command 
respect. 

To  the  doctor,  the  first  duty  is  that  of  obedience — 
absolute  fidelity  to  his  orders,  even  if  the  necessity  of 
the  prescribed  measures  is  not  apparent  to  you.  You 
have  no  responsibility  beyond  that  of  faithfully  carry- 
ing out  the  directions  received.  It  is  true  that  nearly 
all  orders  are  conditional,  and  that  circumstances  may 
occasionally  arise  which  would  render  literal  adherence 
to  the  plan  of  treatment  indicated,  useless  or  even  in- 
jurious, whence  the  necessity  for  an  intelligent  under- 
standing of  the  case  on  the  part  of  the  nurse.  But  only 
the  most  positive  and  evident  reasons  justify  any  depar- 
ture from  her  instructions.  In  a  hospital,  where  a 
medical  attendant  is  always  within  call,  there  will  never 
be  any  occasion  to  assume  such  responsibility.  Here 
military  discipline  should  prevail,  and  implicit,  unques- 
tioning obedience  be  the  first  law  for  the  nurse,  as  for 
the  soldier.  In  private  practice  there  is  more  room 
for  the  exercise  of  judgment,  but  a  good  nurse  is  very 
careful  to  do  not  always  what  seems  to  her  best,  but 


INTRODUCTORY— NURSING  AND  NURSES  5 

what  it  seems  to  her  that  the  doctor  will  best  approve. 
Whatever  may  be  your  own  private  opinion  of  the  course 
pursued,  you  will,  by  conscientiously  carrying  out  your 
instructions,  give  it  every  chance  of  success,  and  never 
permit  yourself  to  express  an  unfavorable  criticism  upon 
it.  Loyalty  to  the  doctor  includes  encouragement  of 
the  patient's  faith  in  him,  so  long  as  he  is  in  charge  of 
the  case.  The  imagination  is  so  largely  active  in  dis- 
ease that  to  infuse  doubt  and  distrust  into  the  patient's 
mind  is  often  to  destroy  all  hope  of  doing  him  good. 
The  nurse  is  a  connecting  link  between  doctor  and  pa- 
tient, responsible  to  the  one,  and  for  the  other,  and  can 
do  much  to  promote  good  feeling  between  them.  Be- 
tween doctor  and  nurse  there  should  be  the  most  per- 
fect accord;  let  him  find  you  always  ready  to  second  his 
efforts  with  an  enthusiasm  equal  to  his  own.  You  owe 
to  him,  finally,  the  utmost  candor  and  truthfulness. 
Nothing  should  induce  you  to  pervert  or  conceal  from 
him  anything  bearing  upon  the  case,  and,  if  you  should 
chance  to  be  so  unfortunate  as  to  make  a  mistake  in 
carrying  out  his  orders,  be  honest  enough  to  promptly 
acknowledge,  and  by  that  means  do  what  you  can  to 
rectify  it. 

Etiquette  requires  that  the  nurse  should  rise  when 
the  doctor  enters  the  room,  and  remain  standing 
while  talking  to  him.  After  making  your  report,  an- 
swering his  questions,  and  seeing  that  he  is  furnished 
with  everything  that  he  is  likely  to  need,  leave  the  room 
and  give  the  patient  a  chance  to  see  him  alone  unless 
you  have  had  special  instructions  to  the  contrary.  In 
this  way  you  will  secure  for  yourself  also  an  opportunity 
for  private  speech. 

To  your  patient  you  owe  attention  to  whatever  can 
affect  his  health  or  his  comfort.  You  must  be  ever  on 
2 


6  A  TEXT-BOOK  OF  NURSING 

the  alert  to  minister  to  and  even  to  anticipate  his  many 
personal  wants.  These  will  vary  so  much  in  different 
cases  that  few  directions  can  be  laid  down  beyond  the 
general  ones  for  constant  watchfulness  and  thoughtful- 
ness.  No  two  patients  are  alike,  and  it  is  by  no  means 
the  greatest  sufferers  who  give  the  most  trouble,  or 
make  the  heaviest  demands  upon  a  nurse. 

There  is  one  necessity  common  to  all  cases,  that  of 
cleanliness.  Keep  him  with  a  clean  skin,  clean  clothes, 
clean  air,  and  clean  surroundings  generally,  and  much 
will  be  done  toward  satisfying  your  patient's  needs. 
This,  of  course,  includes  the  strictest  attention  to  your 
own  person,  which  should  be  an  example  of  cleanliness. 
A  neat  and  attractive  appearance  goes  far  toward  mak- 
ing a  nurse  acceptable.  Your  dress  should  be  fresh  and 
tidy,  of  quiet  colors,  and  with  immaculate  caps  and 
aprons,  if  such  are  worn.  The  hands  especially  should 
be  well  cared  for,  kept  smooth  and  warm,  with  the  nails 
short,  and  well  brushed.  Cold  or  heavy  hands  will  make 
a  patient  shrink  from  your  touch;  long,  sharp  nails  are 
likely  to  scratch  him.  Cultivate  a  touch  at  once  firm 
and  gentle,  light  and  steady. 

The  prejudice  against  cleanliness  and  fresh  air, 
which  even  in  this  enlightened  age  will  frequently  be 
encountered,  must  be  combated  firmly,  though  always 
kindly.  It  is  often  a  matter  of  no  small  difficulty  to 
persuade  a  patient  to  submit  to  having  his  room  suit- 
ably ventilated;  and  almost  equally  prevalent  among  the 
ignorant,  and  still  more  unaccountable,  is  the  dread  of 
clean  clothes. 

Such  notions  must  not,  for  the  patient's  own  sake, 
be  altogether  yielded  to,  neither  should  they  be  allowed 
to  give  rise  to  endless  dissensions.  Cultivate  the  pa- 
tient's confidence  in  your  judgment,  while  making  him 


INTRODUCTORY -NURSING  AND  NURSES  7 

feel  that  you  are  really  his  friend,  ready  and  willing  to 
consult  his  preferences  on  all  minor  matters,  and  he 
will  be  less  likely  to  suspect  you  of  arbitrary  decisions 
upon  others.  Never  use  force  where  persuasion  will 
avail,  even  with  a  delirious  patient,  and  do  not  make 
an  unnecessary  display  of  authority. 

The  authority  must,  however,  exist,  and  will  occa- 
sionally have  to  be  exercised.  You  will  often  be  obliged 
to  insist  upon  things  very  much  against  the  inclinations 
of  your  patient,  and  to  administer  remedies  when  he 
only  desires  to  be  "  let  alone,"  and  no  sentiments  of 
mistaken  tenderness  should  deter  you  from  the  perform- 
ance of  duty,  even  when  it  is  mutually  disagreeable.  It 
is  from  failure  in  this  direction,  as  well  as  from  de- 
fective knowledge,  that  amateur  nursing  is  often  faulty. 
A  calm,  steady  discipline  is  needed  in  the  sick-room — 
that  patient,  cool  control  which  is  far  more  likely  to  be 
exerted  by  a  stranger  than  by  a  relative;  the  very  in- 
tensity of  interest  felt  for  a  dear  friend  often  tending 
to  incapacitate  for  judicious  ministrations.  You  must 
not  allow  the  longing  to  comfort  and  soothe  the  sufferer 
to  blind  you  to  his  real  interest,  yet  be  on  guard  against 
growing  hard  and  unsympathetic  in  this  rigid  adherence 
to  duty.  Undoubtedly  much  familiarity  with  suffering 
does  to  some  extent  blunt  the  sensibilities,  but  the  rela- 
tion between  nurse  and  patient  is  one  of  so  much  de- 
pendence on  the  one  side  and  so  much  helpfulness  on 
the  other,  as  to  tend  to  develop  what  may  be  described 
as  the  maternity  of  nursing.  A  sick  person  is,  for  the 
time  being,  as  a  child,  and  looks  to  his  nurse  for  a 
mother's  care.  From  such  a  relation  a  certain  tender- 
ness of  feeling  almost  inevitably  springs,  and  with  it 
patience  to  bear  with  the  whims  and  irritability  of  the 
sick. 


8  A  TEXT-BOOK  OF  NURSING 

And  a  nurse  soon  learns  to  make  allowance  for  the 
close  connection  between  mental  and  physical  states. 
Invalids  are  often  utterly  unreasonable.  It  is  as  much 
a  part  of  some  diseases  as  the  physical  symptoms,  and 
perhaps  as  little  under  control.  You  will  scarcely  mind 
what  a  sick  person  says  to  you,  so  long  as  you  are  sure 
that  he  has  no  real  ground  for  dissatisfaction.  But  bear 
in  mind  that  diseased  fancies  can  not  be  dissipated  by 
argument;  there  must  be  either  absolute  proof  that 
they  are  unfounded,  or  an  effort  to  do  away  with  the 
cause  of  complaint.  At  least,  do  not  set  a  thing  down 
as  unreasonable,  and  so  do  nothing  about  it,  without 
thorough  investigation.  The  senses  of  the  sick  are  often 
abnormally  acute,  and  a  source  of  discomfort,  as  a  bad 
odor  or  an  unpleasant  draught,  may  make  itself  pain- 
fully evident  to  them,  while  it  is  quite  imperceptible 
to  any  one  else.  There  may  be  many  little  personal 
matters  about  which  other  people  must  know  better 
than  yourself  the  tastes  and  habits  of  your  patient. 
With  regard  to  such  things  you  will  of  course  be  glad 
to  receive  suggestions  and  assistance.  You  will  almost 
always  find  somebody  willing  to  help  in  the  care  of  the 
sick.  You  will  be  fortunate  if  they  do  not  rather  hin- 
der. Often  the  greatest  trial  of  a  nurse  is  the  well- 
meant  interference  of  the  patient's  friends.  If  there 
are  any  among  them  to  whom  you  can  leave  your  pa- 
tient, you  must  bear  in  mind  that  many  details,  matters 
of  course  to  you,  are  likely  to  be  unfamiliar  to  the  in- 
experienced, and  leave  with  your  relief  the  clearest  and 
most  explicit  directions  about  everything  that  is  to  be 
done.  If  in  writing,  there  will  be  so  much  less  room 
for  mistakes.  If  you  have  no  such  relief,  and  find  that 
your  strength  is  being  overtaxed,  state  the  case  to  the 
doctor,  and  ask  for  help.  If,  for  any  reason,  you  find  it 


INTRODUCTORY— NURSING  AND  NURSES          9 

necessary  to  give  up  a  case  the  care  of  which  you  have 
once  assumed,  you  must  at  least  not  leave  it  until  you 
have  seen  your  place  adequately  supplied.  To  leave, 
unadvisedly,  a  patient  in  a  critical  condition  should  be 
regarded  as  a  breach  of  contract;  no  conscientious  nurse 
would  feel  justified  in  doing  it.  With  a  chronic  case, 
of  probable  long  duration,  you  are  under  no  obligation 
to  stay  on  indefinitely,  but  when  you  wish  to  go,  you  will, 
of  course,  give  notice  of  the  fact  in  time  for  other  ar- 
rangements to  be  made.  Under  no  circumstances  ought 
you  to  threaten  the  patient  with  leaving  him. 

As  a  rule,  whatever  tends  to  keep  the  invalid  quies- 
cent and  contented  is  good  for  him,  all  occasions  of 
excitement  bad.  A  tranquil,  peaceful,  though  cheery 
atmosphere  should  prevail.  As  far  as  possible,  let  every- 
thing appear  to  the  patient  to  be  moving  smoothly  and 
easily,  no  matter  what  difficulties  and  annoyances  you 
may  encounter.  Try  to  secure  for  the  sufferer  repose 
of  mind  as  well  as  of  body,  freedom  from  anxiety,  and 
absence  of  all  discussions.  If  he  sees  that  nothing  is 
overlooked  or  forgotten,  he  will  soon  learn  to  have  faith 
in  you,  and  will  gladly  leave  you  to  do  his  thinking  for 
him.  Do  not  call  upon  him  for  decisions,  even  of  small 
matters,  but  decide  for  him.  When  there  is  doubt  in 
your  own  mind  as  to  the  best  plan  to  be  pursued,  con- 
sult, not  the  patient,  but  the  doctor.  Frankly  acknowl- 
edge your  ignorance  to  the  person  from  whom  you  can 
get  the  desired  information.  There  are  very  few  prac- 
titioners who  will  not  be  willing  to  explain  to  you  what 
they  can,  if  they  are  asked  at  the  right  time  and  in  the 
right  way. 

Try  to  find  out  why  things  are  done,  to  be  familiar 
with  underlying  principles  as  well  as  details  of  practice. 
Learn  to  nurse  by  reason  rather  than  by  rule,  for  no 


10  A  TEXT-BOOK  OF  NURSING 

rule  can  be  laid  down  to  which  exceptions  will  not  arise. 
Do  not  fancy  that  after  you  have  heen  through  a  train- 
ing-school you  will  know  all  there  is  to  know  about 
nursing;  in  fact,  you  will  only  have  been  taught  how 
to  learn,  how  to  appreciate  and  profit  by  the  experi- 
ence which  you  will  get.  Every  new  case  will  teach  you 
something  new. 

Says  the  great  English  physiologist:  "If  knowledge 
is  real  and  genuine,  I  do  not  believe  it  is  other  than  a 
very  valuable  possession,  however  infinitesimal  its  quan- 
tity be.  Indeed,  if  a  little  knowledge  be  dangerous, 
where  is  the  man  who  has  enough  to  be  out  of  dan- 
ger! "  Learn,  then,  all  that  you  can — only  take  care 
that  your  knowledge  is  real  and  genuine,  and  not  a  mere 
smattering  of  technical  terms — and  you  may  be  assured 
that  the  more  you  know,  and  the  more  thoroughly  you 
know  it,  the  more  will  you  realize  the  depth  of  your 
own  ignorance,  and  the  less  will  you  dare  to  make  any 
other  than  the  legitimate  use  of  your  knowledge. 

You  will  often  find  yourself  regarded  as  "  next  thing 
to  a  doctor,"  and  be  called  upon  to  furnish  information 
and  give  advice  to  an  extent  quite  beyond  your  prov- 
ince. Just  here  should  be  an  essential  point  of  dif- 
ference between  the  trained  and  the  untrained  nurses. 
It  is  only  the  latter  who  may  be  expected  to  proceed 
to  the  practice  of  therapeutics  on  their  own  account, 
those  who  have  had  no  formal  instruction  as  to  their 
duty,  its  extent  and  its  limits;  not  those  who  are  taught, 
but  those  who  are  untaught,  and  who  have  picked  up, 
in  a  hap-hazard  way,  certain  isolated  facts  regarding 
medical  treatment,  which  they  generalize  and  act  upon. 
The  trouble  with  such  nurses  is  not  that  they  know 
too  much,  but  that  they  know  too  little.  It  is  impos- 
sible that,  with  sickness  and  its  treatment  always  under 


INTRODUCTORY— NURSING  AND  NURSES        11 

their  eyes,  they  should  not  assimilate  some  informa- 
tion; the  only  question  is  whether  they  shall  be  taught 
it  systematically,  and  in  its  proper  relations,  or  whether 
they  shall  be  left  to  appropriate  and  use  it  empirically. 
The  question  has  been  sufficiently  answered  by  the  suc- 
cess of  the  training-schools,  and  the  ever-increasing  de- 
mand for  nurses  trained  to  a  knowledge  befitting  their 
position. 

A  few  very  simple  remedies  only  can  you  recommend 
without  overstepping  the  bounds  of  propriety,  but  you 
will  find  a  broad  field  of  missionary  labor  in  promul- 
gating general  principles  of  hygiene,  sanitary  science, 
and  physical  culture.  Do  not  offer  drugs  for  every  ail- 
ment presented  to  your  notice,  but  show  the  growing 
child  how  to  expand  his  chest  and  carry  himself  erect. 
Explain  to  the  young  girl  just  developing  into  woman- 
hood her  need  for  special  care;  teach  the  tired  mother 
how  to  relax  the  tension  of  her  muscles;  preach  the  vir- 
tues of  cold  water,  simple  diet,  and  rational  exercise, 
and  you  may  be  an  educational  influence  of  inestimable 
value. 

.  In  speaking  of  the  relations  between  nurse  and  pa- 
tient, it  should  not  be  necessary  to  more  than  refer  to 
the  fact  that  a  nurse  occupies  a  position  of  trust,  and 
is  perforce  admitted  to  a  knowledge  of  many  private 
affairs.  No  one  with  any  sense  of  delicacy  can  regard 
as  otherwise  than  inviolably  sacred  what  is  thus  tacitly 
left  to  her  honor.  It  is  true  that  your  patients  will  be 
largely  dependent  upon  you  for  society,  and  that  it  is 
often  difficult  to  produce  conversation  on  demand,  but 
it  is  certainly  possible  to  be  bright,  cheerful,  and  enter- 
taining without  resorting  to  gossip.  To  further  this 
end,  as  well  as  for  your  own  sake,  it  is  advisable  to  go 
occasionally  to  places  of  amusement,  to  read  recent 


12  A  TEXT-BOOK  OF  NURSING 

books,  and  to  keep  yourself  posted  on  matters  of  general 
interest. 

All  these  directions  will  be  seen  to  apply  more  par- 
ticularly to  the  private  nurse.  In  a  hospital,  the  inti- 
mate intercourse  of  the  home  nurse  with  her  patient  is 
impracticable  and  undesirable.  Over-familiarity  is  to 
be  avoided,  and  strict  impartiality  preserved,  but  at  the 
same  time  the  greatest  patience  and  gentleness  may  be 
exhibited,  and  all  possible  regard  for  the  comfort  of  the 
patients. 

The  work  and  the  position  of  the  nurse  are  in  many 
ways  radically  different.  She  is  under  constant  super- 
vision, and  literal  obedience  to  orders  will  carry  her 
safely  through  the  exigencies  of  hospital  service,  but  in 
private  nursing  a  much  greater  responsibility  falls  to 
her  share;  there  is  more  room  for  the  exercise  of  her 
own  judgment,  and  for  the  development  of  her  own  in~ 
dividuality.  The  qualities  required  are  so  diverse  as  to 
be  rarely  found  in  combination.  An  excellent  ward 
manager  may  succeed  but  poorly  as  a  private  nurse,  for 
the  generalship  and  executive  ability  which  count  for 
so  much  in  the  hurry  of  ward  work  become  valueless  in 
comparison  with  the  tact  and  adaptability  so  infinitely 
more  important  in  the  care  of  a  single  patient  at  home. 
The  readiness  with  which  a  nurse  adapts  herself  to  the 
habits  and  idiosyncrasies  of  a  family  which  she  enters 
for  the  first  time,  and  the  degree  of  harmony  which  she 
is  able  to  maintain  with  all  its  members,  are  more  con- 
vincing evidence  of  her  good  sense  and  fitness  for  a  deli- 
cate position  than  the  most  brilliant  examination  pa- 
pers. It  is  in  this  point  that  some  of  our  most  intelli- 
gent nurses  and  best  ward  keepers  fail  when  they  come 
to  the  crucial  test  of  outside  practice. 

You  should  in  each  new  place  make  it  a  rule  to  dis- 


INTRODUCTORY— NUESING  AND  NURSES        13 

turb  as  little  as  possible  the  ordinary  household  arrange- 
ments, however  little  you  may  find  them  to  your  taste, 
and  to  make  no  unnecessary  work.  Any  manifest  con- 
sideration for  the  servants  will  usually  be  repaid  with 
interest,  and  is  to  be  recommended  as  a  matter  of  policy 
if  from  no  higher  motive.  But  the  ideal  nurse,  the  one 
worthy  of  her  high  calling,  is  inspired  by  love,  not 
policy,  and  her  sympathies  are  broad  and  universal. 
Pages  might  be  written1  upon  the  ethics  and  etiquette 
of  nursing,  but  to  little  profit.  The  instincts  of  pro- 
priety and  the  gracious  tact  which  is  the  culmination 
of  culture  can  not  be  taught  by  books.  The  basic  laws 
of  good  morals  and  good  manners  fit  every  situation,  and 
the  minor  adaptations  of  the  conduct  of  life  to  special 
circumstances  are  better  acquired  from  example  than 
precept. 

"  Ask  God  to  give  thee  skill 

In  comfort's  art ; 
That  thou  may'st  consecrated  be, 

And  set  apart 
Unto  a  life  of  sympathy ; 
For  heavy  is  the  weight  of  ill 

In  every  heart ; 

And  comforters  are  needed  much, 
Of  Christ-like  touch." 

A.  E.  Hamilton. 


CHAPTER   II 

"Thank  God  every  morning  when  you  get  up  that  you  have 
something  to  do  which  must  be  done  whether  you  like  it  or  not. 
Being  forced  to  work,  and  forced  to  do  your  best,  will  breed  in 
you  temperance,  self-control,  diligence,  strength  of  will,  content, 
and  a  hundred  virtues  which  the  idle  will  never  know." — Charles 
Kingsley. 

THE  comfort  and  well-being  of  the  invalid  depend 
to  so  great  an  extent  upon  his  surroundings  that,  in 
consideration  of  the  universal  liability  to  illness  and  ac- 
cidents, there  ought  to  be  in  every  well-arranged  house 
an  apartment  chosen  and  especially  fitted  for  the  use  of 
the  sick.  But  the  matter,  in  spite  of  its  importance,  is 
so  generally  ignored  that  it  is  very  rarely  that  a  nurse 
will  have  the  good  fortune  to  find  any  provision  made 
for  such  contingency.  You  will  be  called  upon  to  nurse 
in  all  sorts  of  places,  and  often  under  the  worst  possible 
sanitary  conditions.  It  is  important  to  have  a  clear  idea 
of  what  a  sick-room  ought  to  be,  in  order  to  know  how 
to  choose  the  least  among  unavoidable  evils,  and  how 
best  to  utilize  such  advantages  as  you  may  chance  to 
secure. 

A  model  sick-room  is  spacious,  light,  airy,  clean,  and 
quiet.  The  larger  the  room,  the  better  can  it  be  aired; 
the  more  airy  it  is,  the  cleaner  will  it  be;  and  the 
cleaner  it  is,  the  more  favorable  is  it  for  the  recovery  of 
the  patient.  Space  is  therefore  an  important  considera- 
tion from  a  hygienic  point  of  view.  The  sick-room 
14 


THE  SICK-ROOM  15 

should  be  located  on  the  sunny  side  of  the  house,  having 
a  south  or  west  aspect.  Only  in  exceptional  cases,  such 
as  inflammation  of  the  eye  or  brain,  is  it  necessary  to 
have  the  room  darkened,  and  even  then  a  south  room, 
with  the  light  carefully  moderated  by  blinds  and  shades, 
is  to  be  preferred  to  a  darker  one  on  the  north  side. 
Light  is  a  healthful  stimulus,  and  in  the  majority  of 
cases  not  only  light  but  direct  sunshine  is  to  be  desired, 
partly  for  the  additional  cheerfulness  which  it  imparts, 
but  still  more  because  of  its  actual  physical  effects.  The 
Italians  have  a  proverb,  "  Where  the  sun  does  not  en- 
ter, the  doctor  does,"  showing  their  recognition  of  it 
as  a  powerful  remedial  agent.  Have  as  many  windows 
as  possible,  certainly  no  less  than  two.  They  should 
be  such  as  can  be  opened  at  both  top  and  bottom,  and 
should  reach  nearly  to  the  floor,  that  the  patient  may 
easily  see  out  of  them.,  Bars  and  streaks  of  light  and 
bright  reflections  are  to  be  guarded  against,  as  they  may 
occasion  a  great  deal  of  annoyance. 

The  sick-room  should  be  as  far  as  possible  remote 
from  the  noises  and  odors  of  the  house  and  of  the  street. 
It  should  be  solidly  built,  having  walls  thick  enough  to 
deaden  external  sounds,  and  floors  substantial  enough 
not  to  vibrate  under  every  tread.  Where  this  is  not  the 
case,  manage,  if  possible,  to  have  the  room  above  unoc- 
cupied. There  are  numerous  advantages  to  be  gained, 
especially  in  cities,  by  having  the  sick-room  at  the  top 
of  the  house.  It  will  be  more  quiet,  in  a  stratum  of 
purer  air,  and  in  case  of  contagious  disease  can  be  more 
completely  isolated.  On  no  account  should  there  be 
stationary  basins  in  the  sick-room.  If  you  find  there 
such  modern  conveniences,  cork  up  the  overflow  holes, 
and  fill  the  basin  with  water,  which  must  be  changed 
from  time  to  time,  or  cover  it  entirely  and  closely  with 


16  A  TEXT-BOOK  OP  NURSING 

a  board.  The  increased  security  will  more  than  com- 
pensate for  the  extra  trouble.  Only  with  the  utmost 
precautions  against  leaky  and  defective  traps  are  drain- 
age pipes  to  be  allowed  even  in  the  adjoining  dressing- 
room. 

The  latter  is  an  important  adjunct  to  the  sick-room. 
In  it  are  to  be  kept  the  bath  and  toilet  appurtenances. 
Ample  closet  room  is  also  desirable,  with  shelves-  and 
drawers  for  the  reception  of  linen,  and  of  the  various 
medical  and  surgical  appliances  which  may  be  needed, 
but  which  should  never  be  visible  in  the  sick-room.  It 
is  a  common,  but  very  reprehensible,  practice  to  have 
food,  medicine,  and  all  sorts  of  paraphernalia  lying 
about,  in  a  confusion  that  would  be  enough  to  make  a 
well  person  sick.  They  should  all  be  banished,  except 
at  the  moment  of  actual  use.  Growing  plants,  and 
freshly  cut  flowers  of  not  too  strong  odor,  may  fill  their 
place,  if  desired.  They  are  quite  unobjectionable.  The 
water  in  which  flowers  are  kept  must  be  daily  changed, 
and  the  flowers  themselves  thrown  away  as  soon  as  they 
begin  to  fade.  Do  everything  possible  to  make  the  sick- 
room the  brightest  and  cheeriest  in  the  house.  A  cer- 
tain amount  of  depression  is  the  inevitable  accompani- 
ment of  sickness.  It  can  not  be  entirely  dispelled,  but 
all  counteracting  influences  should  be  brought  to  bear. 
Dark,  gloomy,  and  unpleasantly  suggestive  surround- 
ings do  much  to  intensify  it. 

The  walls  and  ceilings  are  best  of  some  soft,  uniform, 
neutral  tint,  as  pale  green  or  French  gray.  Avoid  wall- 
papers of  conspicuous  tone  or  regularly  recurrent  fig- 
ures. Better  than  any  paper  is  paint,  or  a  hard-finished 
surface  which  can  be  scrubbed.  The  monotony  may  be 
broken  by  pictures,  but  judgment  needs  to  be  exercised 
in  their  selection,  and  no  frames  should  be  used  which 


THE  SICK-ROOM  17 

can  not  be  disinfected.  The  wood-work  should  be  se- 
verely plain  and  flat.  There  should  be  no  cornices  or 
moldings,  and  no  woolen  curtains,  portieres,  or  drapery 
of  any  kind.  All  woolen  stuffs  easily  become  infected, 
and  are  extremely  difficult  to  disinfect.  If  any  curtains 
are  used,  they  should  be  of  light,  washable  material,  and 
should  be  frequently  washed.  Carpets  are  much  better 
dispensed  with.  Hugs  may  be  used  only  if  small  enough 
to  be  daily  removed,  shaken,  and  aired.  If  there  is  car- 
pet, it  can  only  be  thoroughly  swept  and  cleaned  when 
the  patient  can  be  got  out  of  the  room,  but  the  surface 
dust  can  be  removed  quite  effectively  and  noiselessly  by 
means  of  a  damp  cloth  wrapper  around  a  broom.  It  is 
not  a  bad  idea,  especially  in  obstetrical  and  surgical 
cases,  to  cover  a  carpet  with  crash,  where  it  is  not  prac- 
ticable to  take  it  up. 

The  essential  furnishings  of  the  sick-room  are,  a 
bed,  a  bedside  table,  an  easy  chair,  a  lounge,  and  a  large 
movable  screen.  The  latter  can  be  readily  improvised 
by  fastening  a  shawl  or  a  sheet  over  an  ordinary  clothes- 
horse.  Convenient  tables  are  made  with  the  point  of 
support  very  much  on  one  side,  so  as  to  reach  well  over 
the  bed.  They  may  be  raised  or  lowered  to  any  desired 
height.  Bed-trays,  with  a  low  rim  around  three  sides, 
standing  on  legs  high  enough  to  keep  the  weight  entire- 
ly off  the  body,  may  be  used  by  the  patient  for  all  the 
purposes  of  a  table. 

A  bed-rest,  a  commode,  and  similar  small  conven- 
iences may  be  desirable,  but  the  fewer  superfluous  things 
the  better.  All  the  furniture  should  be  of  the  simplest 
possible  style;  elaborate  carvings  only  afford  lodging- 
places  for  dust,  and  whatever  adds  to  the  difficulty 
of  maintaining  absolute  cleanliness  is  to  be  avoided. 
Everything  should  be  substantial  and  in  good  repair. 


18  A  TEXT-BOOK  OF  NURSING 

Ill-fitting  blinds,  rattling  windows,  and  creaking  doors 
are  nuisances  demanding  speedy  remedy. 

Many  slight  and  apparently  unimportant  noises, 
which  are  nevertheless  peculiarly  annoying  to  the  sensi- 
tive nerves  of  the  sick,  may  easily,  with  a  little  care  and 
forethought,  be  done  away  with.  Keep  rocking-chairs 
out  of  the  room.  Avoid  wearing  clothes  that  rustle,  or 
shoes  that  squeak.  If  coal  must  be  put  on  the  fire, 
bring  it  in  wrapped  in  a  paper,  and  lay  it  on,  paper  and 
all.  Use  a  wooden  rather  than  a  metallic  poker  to  rake 
the  fire.  Noise  which  is  understood  and  inevitable  is 
far  less  trying  than  a  much  slighter  noise,  unexplained 
or  unnecessary.  Intermittent  is  more  hurtful  than  con- 
tinuous noise.  Sudden,  sharp,  and  jarring  sounds  are 
especially  bad.  A  good  nurse  never  startles  her  patient. 
Even  in  such  a  small  matter  as  your  way  of  addressing 
him,  be  considerate  of  his  weakness.  Do  not  speak 
abruptly  from  behind  him,  making  him  first  jump,  then 
turn  round,  then  ask  what  you  said,  but  get  his  atten- 
tion before  speaking,  and  use  a  clear,  distinct,  though 
not  necessarily  loud,  voice.  Whispering  in  the  sick- 
room, or  just  outside  the  door,  is  one  of  the  worst  of  the 
many  distressing  forms  in  which  the  solicitude  of  the 
patient's  friends  will  manifest  itself.  There  are  few 
things  more  tormenting,  though  it  is  usually  done  with 
the  very  best  intentions  of  not  disturbing  him.  A  low, 
distinct  tone,  when  conversation  is  necessary,  will  sel- 
dom annoy.  Whispering  always  will,  as  will  any  sound 
which  strains  the  attention,  or  creates  a  sense  of  expec- 
tation. It  should  be  laid  down  as  a  rule  that  whatever 
the  patient  is  not  intended  to  hear  should  not  be  said  in 
his  presence. 

These  seem  very  small  points  to  dilate  upon,  but 
good  nursing  depends  largely  upon  attention  to  details 


THE  SICK-ROOM  19 

so  apparently  trivial  that  a  careless  person  would  never 
think  of  them,  but  which  yet  make  or  mar  the  comfort 
of  the  invalid.  Small  things  assume  momentous  pro- 
portions in  the  limited  interests  of  a  sick-room.  Noth- 
ing is  insignificant  or  beneath  notice  which  has  any 
bearing  upon  the  welfare  of  the  patient.  To  keep  the 
sick-room  in  a  proper  condition  is  as  important  a  part  of 
your  care  for  him  as  more  personal  ministrations.  A 
nurse  ought  not  to  be  expected  to  do  housework,  which 
can  be  equally  well  done  by  some  one  else,  for  she  has 
enough  other  and  more  fitting  demands  upon  her  time 
and  strength,  but,  in  order  to  direct  others,  she  should 
know  exactly  how  it  ought  to  be  done.  The  work  of  a 
nurse  in  a  private  family  varies  so  much  with  circum- 
stances that  its  limits  can  not  be  precisely  defined.  The 
position  is  a  somewhat  anomalous  one,  and,  with  all 
due  regard  for  your  professional  dignity,  surely  you  will 
rather  perform  the  most  disagreeable  and  commonplace 
tasks  than  let  them  go  undone  to  the  detriment  of  your 
patient.  With  the  extra  work  which  sickness  always 
brings,  there  is  often  insufficient  service,  and  the  nurse 
will  be  obliged  to  share  the  burden.  You  must  be  pre- 
pared to  encounter  many  inconveniences;  your  ingenuity 
as  well  as  your  patience  will  often  be  taxed;  and  some- 
times you  will  find  yourself  looked  upon  as  a  kind  of 
machine,  expected  to  run  night  and  day  without  ever 
needing  to  be  wound  up. 

In  a  hospital  there  are  no  difficulties  of  this  sort. 
Everything  is  planned  with  reference  to  the  needs  of  the 
sick;  the  most  convenient  appliances  are  at  hand  as  a 
matter  of  course;  the  duties  of  each  person  are  definitely 
assigned,  and  the  work  as  much  as  possible  simplified  by 
systematic  arrangement  and  regular  hours. 

In  a  ward  of  twenty  patients,  with  the  average  num- 


20  A  TEXT-BOOK  OF  NURSING 

her  of  bad  cases,  there  will  be  usually  three  nurses,  with 
a  maid  or  an  orderly  to  do  the  scrubbing  and  heavier 
work.  The  head  nurse  has  the  oversight  of  them  all, 
and,  present  or  absent,  is  responsible  for  everything 
done  or  left  undone.  Some  assistance  may  be  given  by 
the  convalescent  patients,  though  it  is  an  uncertain  de- 
pendence. Care  must,  of  course,  be  taken  not  to  overtax 
the  strength  of  any  one,  but  they  can  be  made  useful  in 
a  good  many  little  ways,  and  are  usually  glad  of  some 
light  occupation.  Their  work  is,  however,  little  to  be 
relied  upon,  for  a  patient  able  to  do  much  is  likely  to  be 
soon  discharged. 

Ward  work,  in  spite  of  its  variety,  may,  if  skillfully 
planned  and  systematized,  be  reduced  very  much  to  a 
routine.  Minor  arrangements  vary  in  different  institu- 
tions, but  the  fundamental  principles  of  the  nursing 
service  are  everywhere  the  same.  The  nurses  appear  in 
the  ward,  ready  for  duty,  punctually  at  the  appointed 
hour.  The  patients  should  previously  have  had  their 
morning  toilets  made,  under  the  direction  of  the  night 
nurse,  that  there  may  be  no  delay  in  getting  them  ready, 
for  breakfast.  The  head  nurse  first  reads  the  report  of 
the  night,  and  ascertains  any  changes  that  there  may 
be  in  the  condition  of  the  patients  or  in  the  orders  given. 
Unless  she  has  very  competent  assistants,  she  will  then 
herself  attend  to  the  care  of  the  worst  cases  among  the 
bed-patients,  and  to  the  giving  out  of  the  medicines. 
There  are  also  all  the  beds  to  be  made,  the  temperatures 
to  be  taken,  soiled  clothes  to  be  collected  and  sent  to 
the  laundry,  the  ward  generally  to  be  cleaned  up,  and 
the  diet  distributed.  All  these  tasks  are  divided  as  the 
head  nurse  may  direct.  One  assistant  must  take  charge 
of  the  breakfast,  see  that  each  patient  is  served  with  his 
appropriate  allowance,  and  those  fed  who  are  unable  to 


THE  HOSPITAL  WARD  21 

feed  themselves.  Convalescents  should  not  be  allowed 
to  begin  until  all  the  bed-patients  are  attended  to. 
After  the  meal  is  over,  the  dishes  are  to  be  picked  up 
and  carried  out,  and  the  ward  made  ready  for  the  doc- 
tor's visit.  All  this  takes  time,  for  sick  persons  can  not 
be  hurried.  The  nurses  must  all  be  ready  to  attend  the 
staff  upon  their  rounds.  The  head  nurse  must  be  in- 
formed as  to  the  condition  of  every  patient  under  her 
care,  ready  to  answer  any  questions  that  may  be  asked. 
She  must  be  provided  with  a  note-book,  in  which  to 
take  down  on  the  spot  whatever  orders  are  given,  and 
she  should  call  attention  to  everything  which  it  is  im- 
portant for  the  doctor  to  know.  It  is  the  duty  of  the 
assistants  to  keep  her  posted  in  every  particular.  No 
other  speaks  unless  spoken  to.  Absolute  quiet  must 
prevail  in  the  ward  during  rounds.  If  there  are  three 
nurses,  the  senior  goes  on  in  advance  of  the  staff,  and 
expedites  their  progress  by  preparing  each  case  for 
ready  examination.  She  will  know  from  the  nature  of 
the  case  what  is  to  be  done;  the  clothing  must  be  con- 
veniently arranged  without  undue  exposure;  sometimes 
it  will  be  necessary  to  put  screens  about  the  patient,  or 
to  remove  the  dressings  from  a  wound.  The  junior 
nurse,  or  probationer,  following  them,  restores  things 
to  their  previous  orderly  condition,  so  that,  when  the 
rounds  are  completed,  the  ward  will  not  be  in  a  state  of 
general  confusion.  Provision  should  be  made  for  the 
doctors  to  wash  their  hands  before  they  leave  the  ward, 
and  also  after  making  any  physical  examination,  or 
touching  any  wounds,  before  proceeding  to  the  next 
case.  After  they  have  gone,  the  head  nurse  will  ex- 
plain to  her  assistants  the  orders  which  she  has  re- 
ceived, assigning  to  each  such  part  of  the  work  as  she 

wishes  her  to  do.    The  rest  of  the  morning  will  be  occu- 
3 


22  A  TEXT-BOOK  OP  NURSING 

pied  with  the  execution  of  these  orders.  When  any 
hospital  officials  coine  into  the  ward,  the  nurse  in  charge 
should  rise  and  remain  standing  until  they  have  left. 
Other  visitors  should  be  received  with  courtesy,  but 
only  such  questions  answered  as  you  feel  sure  they  have 
a  right  to  ask.  Information  should  not  be  furnished 
freely  to  strangers.  Visitors  should  be  left  alone  with 
their  friends,  and  if  there  is  a  time  limit,  should  be 
notified  when  it  is  reached.  The  nurses  take  turns  in 
going  to  their  own  meals,  that  the  ward  may  never  be 
left  without  a  responsible  attendant.  The  senior  and 
junior  nurses  will  together  attend  to  the  distribution 
of  the  patients'  dinner;  it  is  usually  too  much  for  either 
to  manage  alone.  One  must,  however,  always  be  held 
responsible  for  the  state  of  the  dining-room.  She  must 
see  that  it  is  in  order  before  she  leaves  it,  the  dishes 
washed  and  put  away,  the  refrigerator  clean,  sweet,  and 
locked.  The  dumb-waiter  should  be  kept  closed  when 
not  in  actual  use,  and  no  article  except  food,  and  dishes 
for  food,  ever  be  allowed  on  it. 

After  dinner  the  great  press  of  work  is  likely  to  be 
over,  and,  after  the  ward  is  once  more  in  order,  the 
nurses  may  each  in  turn  be  allowed  an  hour's  absence 
for  recreation.  This  hour  ought,  more  frequently  than 
it  is,  to  be  spent  in  the  open  air.  Later  in  the  day  will 
be  evening  temperatures  to  be  taken,  supper  to  be  given 
out,  and  preparations  to  be  made  for  the  night. 

Besides  these  enumerated,  are  numerous  other 
things  to  be  done  daily.  Old  patients  are  going,  and 
new  ones  continually  coming  in  all  stages  of  dirt  and 
dilapidation. 

When  a  patient  is  admitted,  he  is  at  once  put  to 
bed,  unless  by  special  permission  to  the  contrary.  If  a 
stretcher-patient,  his  coming  will  have  been  previously 


THE  HOSPITAL  WARD  23 

announced,  and  a  bed  prepared  to  suit  the  nature  of  the 
case.  A  list  of  his  clothes  must  be  made,  and  carefully 
verified.  Such  as  need  it  are  to  be  sent  to  the  wash,  or 
to  the  disinfecting  tank,  others  put  away  in  the  ap- 
pointed place.  He  must  have  a  bath,  if  able,  and,  very 
possibly,  also  be  treated  with  some  parasiticide.  His 
temperature  is  to  be  taken,  and  any  marked  symptoms 
reported.  In  a  susceptible  person,  the  change  of  sur- 
roundings, and  consequent  excitement,  may  have  a  con- 
siderable effect  upon  the  pulse,  respiration,  and  even 
temperature;  it  is,  therefore,  advisable  to  take  them  not 
only  immediately  upon  the  entrance  of  the  patient,  but 
again  a  short  time — say  an  hour — later.  Careful  rec- 
ords should  be  kept.  He  will  have  light,  usually  fluid, 
diet  only,  until  special  directions  are  received. 

In  the  same  way  every  event  brings  its  own  demands 
for  more  or  less  time  and  attention.  After  twelve  hours, 
the  day  nurses  will  be  relieved  by  the  night  nurse.  One 
at  least  of  the  former  must  stay  on  duty  until  the  lat- 
ter comes,  even  if  the  day's  work  should  happen  to 
be  done  earlier.  Connections  between  them  must  be 
perfect,  and  the  ward  never  be  left  without  a  nurse  in 
it,  or  within  call.  The  night  nurse  is  subordinate  to 
the  head  nurse  of  the  ward,  and  takes  the  orders  from 
her.  The  doctor,  in  making  his  evening  rounds,  will 
give  additional  directions.  The  duty  of  the  night  nurse 
is  important,  for  all  seriously  sick  people  need  great 
care  at  night,  and  for  others  they  are  often  the  most 
wearisome  hours.  She  needs  to  be  especially  patient, 
kind,  and  gentle,  for  great  demands  are  made  upon  her 
forbearance.  She  must  try  to  get  the  wards  quiet,  and 
the  lights  down  early,  and  to  do  her  work  with  as  little 
commotion  as  possible.  Before  she  goes  off  in  the  morn- 
ing, besides  making  a  verbal  report  to  the  head  nurse, 


24  A  TEXT-BOOK  OF  NURSING 

she  must  prepare  for  the  doctor  a  written  record  of 
everything  noteworthy  which  has  occurred  during  the 
night. 

For  work  to  go  on  smoothly,  there  needs  to  be  the 
greatest  harmony  and  accord  among  all  the  nurses. 
They  have  devoted  themselves  to  a  common  object,  with 
which  no  petty  personal  feeling  should  ever  be  allowed 
to  interfere.  No  nurse  is  fit  for  her  position  who  will 
sacrifice  to  any  narrow  jealousies  or  disputes  the  work- 
ing order  of  her  department. 

All  that  has  been  said  of  the  care  of  the  sick-room 
applies  with  even  stronger  emphasis  to  the  hospital  ward, 
where  a  greater  number  of  lives  are  at  stake.  The  first 
requisite  is  scrupulous  cleanliness.  No  amount  of  ven- 
tilation will  keep  the  air  sweet  in  a  ward  that  is  not 
clean.  It  has  been  sagely  remarked,  that  "  dust  in  a 
ward  is  not  only  dirt  but  danger."  It  consists  largely 
of  organic  matter,  which  must  be  taken  away,  not  mere- 
ly stirred  up  and  redistributed.  Nothing  really  removes 
dust  but  a  damp  cloth  or  sponge,  to  which  it  will  ad- 
here. To  sweep  properly  a  room  full  of  people  requires 
more  care  than  a  maid  will,  without  special  oversight, 
be  inclined  to  give.  The  ordinary  flourish  of  brooms 
raises  a  cloud  of  dust,  and  drives  it  over  the  beds,  and 
into  the  eyes  and  mouths  of  their  unfortunate  occu- 
pants. On  a  hard  floor,  a  soft-hair  broom  should  be 
used  or  a  dry  "  dust-mop."  Water  for  washing  floors 
should  be  often  renewed,  and  not  too  freely  used.  Vig- 
orous rubbing  with  a  cloth  or  carriage  sponge,  wrung 
out  nearly  dry,  will  do  more  good  than  a  deluge  of  dirty 
water.  During  the  sweeping,  the  rugs  should  be  taken 
out  of  doors  and  shaken.  Some  dust  will  of  necessity 
escape  into  obscure  nooks  and  corners,  all  of  which 
should,  therefore,  be  under  strict  supervision.  Dusting, 


THE  HOSPITAL  WARD  25 

except  of  metallic  surfaces,  must  be  done  with  a  damp 
cloth,  followed,  if  need  be,  with  a  dry  after-polish.  The 
feather-duster  in  common  use  is  worse  than  worthless, 
except  to  bring  down  to  an  accessible  height  dirt  that  is 
out  of  reach,  for  it  serves  only  to  scatter  the  dust  and 
make  it  less  conspicuous,  a  disadvantage  rather  than  a 
desideratum. 

All  vessels  must  be  removed  from  the  ward  imme- 
diately upon  use,  and  thoroughly  cleaned;  all  waste  mat- 
ter, even  water  used  for  washing,  should  be  at  once 
carried  out.  Communicating  passages,  bath-rooms,  and 
closets,  as  well  as  the  ward  itself,  must  be  under  strict 
supervision,  for  it  is  of  little  use  to  have  an  immaculate 
ward,  if  every  time  a  door  is  opened  it  gives  admittance 
to  a  gust  of  unclean  air  from  some  dusty  or  ill-venti- 
lated lavatory.  To  keep  the  lavatories  free  from  odor 
needs  special  care.  Water-closets  should  be  thoroughly 
flushed,  and  have  some  disinfectant  poured  down  them 
daily.  Any  failure  of  water  supply,  or  discovery  of  im- 
perfect drainage,  must  be  at  once  reported  to  the  proper 
authorities.  There  should  be  not  a  hole  or  corner  any- 
where which  will  not  bear  the  most  rigorous  inspection. 
All  basins,  bath-tubs,  and  metal  fixtures  must  be  kept 
bright  and  shining. 

Kemove  from  the  ward  promptly  all  soiled  clothes. 
Before  sending  them  to  the  laundry  see  that  no  pins  are 
left  in  them,  that  they  are  distinctly  marked  with  the 
name  or  number  of  the  ward,  and,  if  private  'property, 
with  the  name  of  the  patient.  Roll  very  dirty  things 
in  a  bundle  by  themselves.  A  list  must  be  made  out, 
of  which  a  duplicate  is  retained,  for  comparison  when 
the  clothes  are  returned. 

Cleanliness,  everywhere  "  next  to  Godliness,"  in  a 
hospital  ward,  takes  precedence  of  all  other  virtues: 


26  A  TEXT-BOOK  OF  NURSING 

"  Order,  heaven's  first  law/'  has  a  secondary,  but  still 
an  important  place.  A  well-kept  ward  is  characterized 
by  neatness  and  uniformity.  A  little  care  to  have 
things  straight  adds  much  to  its  attractiveness  of  ap- 
pearance. The  beds  should  be  in  an  exact  line,  curtains 
at  an  equal  height,  chairs,  tables,  and  rugs  at  the  same 
angle  to  each  other.  Few  things  give  a  ward  a  more 
disorderly  effect  than  clothes  tucked  about  the  beds 
or  tables,  or  flung  over  chairs.  The  bedside  tables  must 
be  daily  inspected,  and  no  rubbish  allowed  to  accumu- 
late in  them.  Unless  carefully  watched,  patients  are 
very  apt  to  stow  away,  in  the  nearest  place,  dirty  clothes, 
relics  of  meals,  dead  flowers,  apple  skins,  or  any  refuse 
that  may  need  to  be  disposed  of.  Eefuse-cans  should 
be  provided,  always  of  metal,  with  tightly  fitting  covers. 
They  should  never  under  any  circumstances  be  allowed 
to  stand  uncovered.  They  will  need  to  be  scoured  out 
frequently  with  some  strong  disinfecting  solution. 

Nothing  should  be  thrown  out  which  can  be  in  any 
way  utilized.  If  supplies  are  liberally  furnished,  do 
not,  therefore,  think  that  little  bits  are  of  no  account, 
but  make  them  go  as  far  as  possible.  Hospital  supplies 
are  of  an  expensive  nature,  and  it  is  the  nurse's  duty  to 
see  that  nothing  is  wasted.  See  also  that  supplies  are 
well  kept  up;  everything  expected  to  be  on  hand  re- 
newed before  it  is  quite  exhausted.  In  a  surgical  ward, 
the  dressing-basket  should  stand  in  some  accessible 
place,  furnished  with  everything  likely  to  be  called  for 
in  an  ordinary  dressing. 

To  keep  things  in  order,  it  is  necessary  to  work 
neatly,  and  clear  up  after  each  performance  before  un- 
dertaking another.  Much  confusion  will  be  avoided  by 
getting  everything  ready,  even  to  the  smallest  detail, 
before  beginning  any  process.  Have  a  clear  idea  in 


THE  HOSPITAL  WARD  27 

mind  of  what  is  to  be  done,  and  never  get  excited.  You 
will  then  be  able  to  be  prompt  without  hurrying,  quiet 
and  methodical  in  movement,  and  will  doubtless  soon 
achieve  a  reputation  as  a  neat  and  skillful  nurse. 

"  The  trivial  round,  the  common  task, 
Will  furnish  all  we  ought  to  ask. 
Room  to  deny  ourselves,  a  road 
To  bring  us  daily  nearer  God." 

John  Keble. 


CHAPTER   III 

"  In  bed  we  laugh,  in  bed  we  cry, 
And  born  in  bed,  in  bed  we  die. 
The  near  approach  a  bed  may  show 
,        Of  human  bliss  to  human  woe ! " 

Isaac  de  Benserade  (trans,  by  Samuel  Johnson). 

IT  is  the  common  notion  that  anybody  can  make  a 
bed,  and  possibly  also  that  it  is  of  very  little  account 
exactly  how  a  bed  is  made.  To  a  thoroughly  healthy 
person,  who  will  sleep  soundly  all  night  and  turn  out  of 
bed  as  soon  as  he  wakes,  it  does  not  indeed  matter 
much,  although  he  spends  a  third  of  his  life  in  it, 
whether  his  bed  be  well  or  ill  made,  so  long  as  it  is 
clean  and  warm.  But  the  invalid,  whose  confinement 
to  it  is  more  or  less  permanent  and  compulsory,  and 
the  acuteness  of  those  sensations  is  aggravated  by 
disease,  finds  few  things  more  seriously  affecting 
his  comfort  than  the  condition  of  his  bed.  To  know 
how  best  to  arrange  and  take  care  of  it  is  very  im- 
portant for  the  nurse.  When  you  take  charge  of  a 
private  patient,  who  has  been  till  then  cared  for  by 
home  talent,  in  nine  cases  out  of  ten  the  first  thing  you 
will  find  it  necessary  to  do  will  be  to  reconstruct  the 
bed,  and  often  the  skillful  rendering  of  this  simple 
service  will  at  once  call  forth  the  gratitude  of  your 
patient,  and  gain  his  instant  recognition  of  your 
efficiency. 

Let  us  first  consider  the  frame  upon  which  the  bed 
28 


BEDS  AND  BED-MAKING  29 

is  supported.  Wooden  bedsteads  should  not  be  used  for 
the  sick  when  anything  else  can  be  obtained.  The  best 
are  those  common  in  our  hospitals,  made  entirely  of 
metal,  iron,  or  brass,  with  a  mattress  of  woven  wire. 
These  can  be  kept  in  a  clean  and  wholesome  condition 
more  easily  than  any  other,  and  are  for  use  in  the  sick- 
room far  superior  to  those  ordinarily  found  in  private 
houses.  They  are  non-absorbent,  and  afford  no  hiding- 
places  for  vermin,  which,  in  spite  of  all  precautions,  will 
sometimes  appear,  even  in  well-regulated  homes,  and  to 
which  public  hospitals,  with  their  miscellaneous  class  of 
patients,  are  especially  liable.  The  first  sign  of  a  bug 
should  be  the  signal  for  a  most  careful  search  and  ex- 
termination, for,  once  having  gained  a  foothold,  they 
multiply,  as  every  housekeeper  knows,  with  alarming 
rapidity.  Corrosive  sublimate  is  the  surest  remedy,  but, 
being  a  violent  poison,  it  must  be  handled  with  caution. 
Another  exterminator,  recommended  for  all  kinds  of 
vermin,  has  the  following  formula:  Aqua  ammonia,  two 
ounces;  saltpetre,  one  ounce;  soap,  scraped,  one  ounce; 
soft  water,  one  quart. 

Bedsteads  should  be  on  castors,  so  as  to  be  easily 
moved,  and  should  be  no  heavier  than  is  necessary  for 
strength.  It  is  better  to  have  castors  upon  two  legs 
only,  at  the  head  of  the  bed,  rather  than  upon  all  four. 
This  will  secure  ease  of  movement  when  necessary  and 
at  the  same  time  keep  it  from  being  moved  inadvertent- 
ly, which  may  cause  annoyance.  The  best  dimensions 
for  a  bed  in  which  a  sick  person  is  to  be  cared  for,  are 
six  and  a  half  feet  long,  three  feet  wide,  and  two,  or  at 
most,  two  and  a  half,  feet  high.  If  it  is  too  wide,  the 
nurse  will  be  unable  to  reach  the  patient  without  get- 
ting upon  the  bed  herself,  which  is  always  an  objection- 
able proceeding;  if  it  is  too  high,  it  adds  to  the  difficulty 


30  A   TEXT-BOOK  OF  NURSING 

of  raising  the  patient,  and  makes  it  harder  for  convales- 
cents to  get  in  and  out. 

Over  the  wire  springs  will  be  placed  a  mattress  of 
some  kind.  For  this  various  materials  are  used — hair, 
straw,  jute,  felt,  etc.  Straw  has  the  advantage  of  cheap- 
ness, and  the  ticks  can  be  frequently  emptied,  washed, 
and  refilled,  while  the  old  straw  is  burned;  but  hair  of 
good  quality  makes  the  most  comfortable  bed,  being  at 
once  firm  and  elastic.  It  can  be  cleaned  and  subjected 
to  a  disinfecting  temperature  without  injury.  This  is 
also  true  of  the  so-called  "  felt "  mattress,  which,  con- 
sisting simply  of  layers  of  cotton  batting,  is  much  less 
expensive,  while  both  comfortable  and  durable.  Hos- 
pital mattresses  are  frequently  made  in  sections,  as  they 
wear  more  evenly,  and  a  part  can  be  renewed  without 
taking  to  pieces  the  whole.  When  this  is  done  it  is 
well  to  have  the  sections  tacked  strongly  together,  as 
they  are  otherwise  apt  to  slip  apart,  leaving  an  uncom- 
fortable crack  under  the  patient.  Still,  an  expert  bed- 
maker  will  get  the  under  sheet  tight  enough  to  hold 
them  in  place.  In  some  surgical  cases  it  is  necessary 
to  have  a  part  removable,  to  allow  the  application  of 
mechanical  apparatus. 

A  feather-bed  is  a  thing  never  to  be  thought  of  in 
connection  with  the  sick-room,  being  a  combination  of 
every  objectionable  quality.  Its  use  is  nearly  equivalent 
to  putting  the  patient  into  an  immense  poultice;  it  is 
warm,  soft,  absorbent,  and  consequently  nearly  always 
damp.  Unless  it  is  stuffed  unusually  full  the  patient 
sinks  at  once  into  a  hole;  it  is  impossible  to  keep  it 
level,  and,  if  it  once  gets  wet,  there  is  no  way  of  reno- 
vating it.  Once  in  a  while,  one  comes  across  some  old 
lady,  who,  from  long  usage,  has  become  so  attached  to 
her  feather-bed  as  to  fancy  that  she  can  not  sleep  on 


BEDS  AND  BED-MAKING  31 

anything  else.  If  she  is  able  to  leave  it  daily,  to  have 
it  shaken  up  and  rearranged,  it  is  scarcely  worth  while 
to  struggle  against  the  prejudice;  but  if  she  is  likely  to 
be  confined  to  bed  for  any  length  of  time,  the  first  thing 
to  be  done  is  to  persuade  her  to  give  it  up,  for,  offering 
as  it  does  every  condition  favorable  to  the  development 
of  bed-sores,  it  will  be  a  source  of  danger  as  well  as  of 
discomfort.  After  a  few  days'  trial,  even  the  most  per- 
sistent lover  of  the  feather-bed  will  usually  be  convinced 
of  the  superiority  in  sickness  of  an  unyielding  support. 
If  not,  and  the  sufferer  still  clings  to  her  old  habits,  then 
we  are  sorry  for  the  nurse,  for  she  has  a  hard  task  be- 
fore her.  In  many  surgical  cases  it  is  of  great  impor- 
tance that  the  bed  be  kept  flat  and  level.  Where  extra 
firmness  is  required  a  thick  board,  the  size  of  the  mat- 
tress, is  placed  under  it.  This  is  known  as  a  fracture- 
board.  It  should  have  holes  in  it  for  ventilation,  or  a 
frame  of  slats  may  take  its  place. 

The  propensity  of  hospital  patients  to  stow  away 
their  personal  property  under  the  mattresses  should  be 
provided  against.  Give  them  other  safe  and  convenient 
places  in  which  to  put  their  things,  and  insist  upon  hav- 
ing the  beds  kept  clear. 

For  sheets,  cotton  is  a  better  material  than  linen. 
The  latter,  being  a  good  conductor  of  heat  and  a  rapid 
absorber  of  moisture,  has  a  tendency  to  chill  the  surface 
of  the  body;  cotton  does  not  conduct  away  the  heat  so 
rapidly,  and  is,  therefore,  safer  for  the  use  of  the  sick. 
Sheeting  comes  in  widths  adapted  for  beds  of  different 
sizes.  Whatever  the  width  of  the  sheet,  the  length 
should  exceed  that  of  the  bed  by  three-quarters  of  a 
yard. 

In  making  the  bed  spread  the  lower  sheet  smoothly 
and  tightly  over  the  mattress,  tucking  it  in  securely  on 


32  A  TEXT-BOOK  OP  NURSING 

all  sides.  It  can  be  made  still  more  firm,  if  the  bed  is 
being  prepared  for  long  occupancy,  by  fastening  it  with 
safety-pins  to  the  mattress.  Be  careful  that  the  sheet 
is  put  on  straight,  for,  if  not,  it  will  form  wrinkles, 
and,  if  pinned,  be  likely  to  tear.  There  should  not  be 
a  blanket  between  the  under  sheet  and  the  mattress.  It 
may  be  necessary  to  protect  these  from  discharges  by  a 
piece  of  rubber  cloth,  covered  by  a  second  folded  sheet, 
or  a  narrower  "  draw-sheet."  The  latter,  as  its  name 
implies,  may  be  easily  drawn  from  under  the  patient 
with  very  little  disturbance  to  him,  while  another  is  at 
the  same  time  slipped  into  its  place.  The  water-proof 
and  draw-sheet  must  both  be  stretched  as  tightly  as  pos- 
sible, and  well  tucked  in.  The  hem  should  always  be 
at  the  top.  When  rubber  sheeting  can  not  be  obtained, 
enameled  cloth  or  oiled  muslin  will  answer  the  purpose, 
or,  in  an  emergency,  heavy  brown  wrapping-paper  is  a 
fairly  good  substitute.  The  rubber,  being  only  for  the 
protection  of  the  bed,  should  not  be  retained  longer 
than  is  really  necessary,  as  the  patient  may  be  more  com- 
fortable without  it. 

The  upper  clothing  should  be  enough  for  warmth, 
but  no  more;  for  too  much  warmth  is  enervating,  and 
too  much  weight  impedes  respiration.  There  will  be 
first  another  sheet,  tucked  in  well  at  the  foot,  that  it 
may  not  be  pulled  out  of  place,  but  left  long  enough  to 
turn  down  for  some  little  distance  over  the  blankets. 
A  woolly  surface  coming  in  contact  with  the  face  is 
usually  very  disagreeable,  though,  in  some  cases,  where 
there  is  special  need  for  warmth,  as  in  acute  rheuma- 
tism, the  patient  will  be  put  directly  between  the  blank- 
ets. Blankets  of  good  quality  are  the  best  bed-covering, 
being  warm,  and  not  weighty.  Double  ones  should  al- 
ways be  separated.  They  should  come  up  high  enough 


BEDS  AND  BED-MAKING  33 

to  tuck  in  snugly  around  the  throat,  if  desired;  but  the 
patient  should  not  he  allowed  to  sleep  with  his  head 
iinder  the  bedclothes,  breathing  the  noxious  emanations 
from  his  body.  Several  thin  coverings  will  be  warmer 
than  a  single  one  of  equal  weight,  because  of  the  non- 
conducting air  inclosed  between  them.  Heavy  quilts 
and  counterpanes  will  be  found  burdensome.  The  old- 
fashioned  cotton  comforter  is  heavy,  and  not  propor- 
tionately warm.  Eider-down  quilts  are  luxuriously  light 
and  soft,  but  can  not  be  well  cleaned  or  disinfected.  A 
patient  sleeping  under  one  should  be  carefully  watched, 
as  it  is  likely  to  induce  excessive  perspiration.  If  one 
desires  to  avoid  the  weight  of  a  counterpane,  a  clean 
white  sheet  will  take  away  the  unfinished  look  of  the 
blankets  alone,  and  at  the  same  time  protect  them  from 
dust.  Counterpanes,  being  chiefly  ornamental  additions 
to  the  outfit  of  the  bed,  may  as  well  be  taken  off  at  night, 
and  so  kept  clean  the  longer.  An  extra  blanket  will  be 
needed  toward  morning,  and  should  always  be  at  hand. 
Blankets,  as  well  as  sheets,  need  washing  whenever  they 
are  stained  or  dingy,  or  are  taken  from  infected  beds. 
Fresh  blood-stains  can  be  removed  from  blankets  or 
ticking  by  spreading  over  the  spot  a  paste  of  fine  starch 
or  wheat  flour,  and  allowing  it  to  dry.  If,  upon  rubbing 
it  off,  it  is  found  that  the  stain  has  not  entirely  dis- 
appeared, a  second  application  will  be  pretty  sure  to 
be  effectual.  Blood  and  other  stains  can  be  removed 
from  rubber  by  Labarraque's  solution  (of  chlorinated 
soda). 

The  beds  in  a  hospital  ward  should  be  made  to  look 
as  nearly  alike  as  possible,  the  surfaces  even,  the  spreads 
equally  far  from  the  floor  on  both  sides,  and  with  the 
corners  arranged  at  the  same  angle.  In  some  hospitals 
the  convalescents  make  their  own  beds;  but  a  great  lack 


34  A  TEXT-BOOK  OF  NURSING 

of  uniformity  results,  detracting  much  from  the  neat 
appearance  of  the  ward. 

The  sick-bed  should  stand  far  enough  from  the  wall 
to  he  accessible  on  all  sides.  It  should  be  in  such  posi- 
tion that  its  occupant  can  look  out  of  the  window,  but 
whatever  artificial  light  is  employed  is  best  behind 
him. 

Nothing  should  be  allowed  under  the  bed,  nor  should 
there  be  any  drapery  to  prevent  the  free  circulation  of 
air  below  it.  The  bed  should  stand  steadily,  so  as  not 
to  be  easily  jarred.  Sitting  on  the  bed,  leaning  against 
it,  or  in  any  way  shaking  it,  occasions  great  discomfort 
to  the  patient.  Sometimes  even  the  touch  of  the  bed- 
clothes can  not  be  endured.  They  may  then  be  sup- 
ported over  the  seat  of  pain  by  "  cradles  " — frames  of 
iron  or  wood  made  for  the  purpose.  The  two  halves  of 
a  barrel-hoop  tied  together  in  the  middle  will  make  a 
fairly  good  one;  or,  for  a  limb,  a  bandbox,  split  through 
the  center.  Or  the  clothes  may  be  lifted  on  a  strong 
cord  running  diagonally  from  the  head  to  the  foot  of 
the  bed. 

For  changing  a  sheet  or  draw-sheet,  while  the  pa- 
tient is  in  bed,  the  method  usually  recommended  is  to 
roll  the  soiled  sheet  lengthwise,  from  the  edge  of  the 
bed  farthest  from  the  patient,  till  it  reaches  him.  The 
clean  sheet,  previously  rolled  in  the  same  way,  is  then 
unrolled  over  the  space  from  which  the  first  was  taken, 
until  the  two  rolls  lie  side  by  side.  The  patient  may 
then  be  lifted  or  turned  over  on  to  the  clean  sheet,  the 
soiled  one  being  removed,  and  the  rest  of  the  clean  one 
unrolled.  Instead  of  rolling  the  sheets,  it  is  better  to 
fold  them  alternately  backward  and  forward  in  the 
manner  illustrated  by  Fig.  B,  as  the  folds  lie  flatter  than 
the  roll,  and,  when  the  upper  one  is  pulled,  the  others 


BEDS  AND  BED-MAKING  35 

readily  follow.  This  is  more  easily  manageable,  and  is 
less  likely  to  become  tangled  than  the  more  compact 
roll.  If  it  is  not  advisable  to  move  the  patient,  even 
from  one  side  of  the  bed  to  the  other,  the  mattress  may 
be  pressed  down,  while  the  clean  and  soiled  sheets  are 
together  gradually  worked  under  his  body.  The  head 


and  feet  can  be  slightly  raised  to  allow  the  folds  to 
pass.  It  requires  two  persons  to  do  this  easily. 

The  upper  sheet  can  be  changed  with  even  less 
trouble  and  without  exposure.  Free  the  clothes  at  the 
foot  of  the  bed.  Spread  the  clean  sheet  outside  of  them 
all,  over  it  a  blanket,  and  tuck  them  in  securely  before 
removing  the  first  set.  Finally,  slip  these  from  under 
the  clean  sheet,  and  carry  the  blanket  out  to  air.  If  the 
extra  blanket  is  not  at  hand,  the  clean  sheet  may  be 
rolled  or  folded  across  its  width,  tucked  in  at  the  bot- 
tom, and  unrolled  toward  the  top  under  everything  else, 
the  soiled  sheet  being  afterward  pulled  down  and  re- 
moved at  the  foot.  See  that  the  blankets  are  made 
smooth  and  straight.  If  they  are  not  wide  enough  to 
tuck  in  well  at  the  side,  the  upper  one  may  be  laid  on 
across  the  others;  otherwise  they  will  all  be  dragged  off 
on  one  side  when  the  patient  turns  over. 

The  common  custom  of  taking  a  crumpled  upper 
sheet  and  putting  it  on  in  place  of  a  soiled  lower  one  is 
not  good  economy  in  sickness.  If  there  can  be  only  one 


36  A  TEXT-BOOK  OF  NURSING 

clean  sheet  given,  let  it  be  the  one  on  which  the  patient 
has  to  lie.  His  comfort,  unless  he  has  an  unusual  re- 
gard for  appearances,  depends  more  upon  having  a 
smooth,  fresh  surface  under  him  than  upon  having  it 
where  it  will  show  the  most.  The  sheets  ought  to  be 
changed  frequently — at  least  one  every  day,  if  only  to 
be  aired  and  used  again.  See  that  all  clean  articles  like- 
ly to  be  needed  are  at  hand  before  removing  the  soiled, 
and  that  they  are  well  aired  and  warmed.  Dampness  in 
bed  or  bedding  is  always  dangerous.  If  the  bed  feels 
close  and  unpleasant,  it  may  be  to  some  extent  aired  by 
lifting  the  clothes  at  the  edge  of  the  bed,  and  fanning 
them  up  and  down  a  few  times.  This  may  be  done  with- 
out danger  of  chilling  the  patient,  and  will,  especially  in 
warm  weather,  be  found  refreshing. 

If  you  can  not  change  the  sheets,  pull  them  as  tight 
and  as  straight  as  possible,  which  will  give  a  fresh  feel- 
ing to  the  bed.  The  best  possible  arrangement  is  to  have 
two  of  the  narrow  beds  above  described,  from  one  to  the 
other  of  which  the  patient  can  be  daily  moved.  Each  is 
to  be  supplied  with  its  own  complement  of  bedding, 
one  set  being  aired  while  the  other  is  in  use.  Even  a 
very  sick  person  can  be  easily  moved  by  two  attendants, 
one  standing  at  his  head  and  the  other  at  his  feet.  The 
second  bed  must  be  placed  as  closely  as  possible  by  the 
side  of  the  first,  then  the  sheet  upon  which  the  patient 
lies  is  lifted  by  the  corners  and  is  carried  steadily  over. 
He  must  be  lowered  slowly,  gently,  and  without  jarring. 
Then  slip  from  under  him  the  sheet  on  which  he  has 
been  moved.  Be  sure,  before  you  begin,  that  this  is  a 
strong  one,  with  no  rent  in  it  that  may  give  way.  Two 
poles  or  long  brush-handles,  rolled  tightly  into  the  sheet 
to  within  a  few  inches  of  the  patient's  body,  will  con- 
vert it  into  an  impromptu  stretcher,  upon  which  he 


BEDS  AND  BED-MAKIKG  37 

may  be  kept  perfectly  horizontal  during  the  moving 
process. 

If  the  two  beds  are  of  exactly  equal  height,  you  may 
be  able  to  accomplish  the  transfer  alone.  One  way  to  do 
it  is  to  pin  a  stout  rubber  cloth  to  the  bed  from  which 
you  wish  to  move  your  patient,  letting  it  lap  over  on  to 
the  other  so  as  to  cover  the  intervening  crack  and  give"  a 
level  surface,  across  which  he  may  be  drawn  by  means  of 
the  sheet  on  which  he  lies.  Or,  having  the  two  beds 
side  by  side,  pull  the  mattress  with  the  patient  on  it  a 
little  way  over  the  other.  He  may  then  be  slid  down  on 
to  the  fresh  bed,  and  the  first  taken  away.  This  is  easy 
if  the  mattress  is  not  too  thick  and  heavy. 

If  the  patient  is  light,  the  easiest  way  of  all  may  be 
to  carry  him,  putting  one  arm  under  the  knees,  and 
with  the  other  supporting  the  back  just  below  the 
shoulders,  but  this  is  scarcely  advisable  except  in  case  of 
a  child. 

All  this  is  assuming  that  the  sick  person  is  perfectly 
helpless.  If  he  can  help  himself  a  little,  it  of  course 
makes  the  matter  still  less  difficult.  To  move  him  into 
another  bed,  although  it  seems  like  a  great  undertaking, 
is  really  little  more  trouble  than  to  rearrange  his  own 
under  him,  while  it  makes  him  more  comfortable,  and 
gives  an  opportunity  to  thoroughly  air  each  bed.  There 
are  a  few  surgical  cases — fracture  of  the  thigh,  etc. — 
in  which  such  a  change  is  impracticable,  and  in  a  pri- 
vate house  one  is  not  always  able  to  command  hospital 
conveniences.  Where  one  wide  bed  must  be  used,  some 
of  the  advantages  of  two  may  be  obtained  by  using  alter- 
nate sides  of  it.  One  half  may  be  kept  for  the  daytime 
and  the  other  for  the  night. 

Be  especially  generous  with  pillow-cases.  Have 
clean  ones  often.  Pillows  need  to  be  frequently 


38  A  TEXT-BOOK  OP  NURSING 

changed,  or  shaken  up  and  turned,  as  they  soon  become 
hot  and  uncomfortable.  In  doing  this,  lift  the  patient's 
head  carefully,  and  let  it  rest  on  one  arm,  while  with 
the  other  hand  the  desired  arrangement  is  effected. 
Then  lay  him  back  gently;  do  not  let  his  head  drop 
with  a  jerk. 

'  To  prop  up  a  patient  with  pillows,  first  see  that  one 
is  pushed  well  down  against  the  small  of  his  back,  and 
then  put  eacH  additional  pillow  behind  the  last.  This 
will  keep  them  from  slipping,  and  will  support  the  back 
without  interfering  with  the  play  of  the  lungs.  A  sin- 
gle long  pillow,  stuffed  hard,  thick  at  one  end  and  grad- 
ually diminishing  toward  the  other,  like  a  wedge,  is 
better  for  this  purpose  than  half  a  dozen  of  the  ordinary 
kind.  One  or  two  softer  ones  may  be  placed  on  top  of 
it.  Wooden  bed-rests  are  made,  and,  for  temporary  use, 
a  straight-backed  chair,  turned  upside  down,  is  very 
good.  Bed-rests  of  netting,  secured  at  each  end  to  the 
bedstead,  are  said  to  be  very  cool  and  airy.  They  can 
be  so  arranged  as  to  swing  the  patient  quite  off  the  bed. 
For  a  weak  patient,  with  an  inclination  to  slip  down  to 
the  foot  of  the  bed,  Cullingsworth's  roller-pillow  is  val- 
uable. This  is  a  cylindrical  cushion,  some  four  inches 
thick,  with  a  strip  of  stout  webbing  at  each  end  fasten- 
ing it  securely  to  the  head  of  the  bed.  The  patient  sits 
upon  this,  as  it  were,  and  is  supported  by  it.  There  are 
an  endless  number  of  invalids'  beds  made  to  tip  up  at 
various  angles,  and  several  forms  of  patent  apparatus 
for  lifting  and  holding  up  the  patient  while  the  bed  is 
being  arranged  under  him.  A  very  simple  and  useful 
appliance  for  enabling  the  invalid  to  help  himself  is 
a  strap  with  a  handle,  pendant  from  a  hinged  crane  over 
the  bed,  or  from  a  ring  in  the  ceiling. 

Small  pillows  of  various  sizes  and  shapes  are  fre- 


BED-SORES  39 

quently  serviceable.  Rubber  air-cushions  are  especially 
comfortable.  They  should  be  smoothly  covered,  and 
the  cover  should  be  sewed,  not  pinned,  on.  In  some 
cases  an  air-  or  water-bed  will  be  called  for.  They  are 
both  made  of  rubber;  the  former  is  filled  by  bellows,  the 
latter  is  connected  with  a  hose.  The  air-mattress  may 
be  placed  on  an  ordinary  bedstead,  but  the  water-bed 
lies  in  a  wooden  trough.  An  old  blanket,  or  cloths,  must 
be  put  under  it  to  keep  it  from  sticking.  The  water 
with  which  it  is  filled  should  be  at  a  temperature  of 
about  70°  Fahr.  Cover  with  a  blanket  before  putting 
on  the  usual  bedding.  Care  must  be  taken  to  avoid 
pricking  water-  or  air-cushions,  or  beds.  All  rubber 
goods  need  careful  handling.  They  dry  out  and  dete- 
riorate rapidly,  especially  when  not  in  use.  They  should 
not  be  put  away  in  a  cold  room,  as  freezing  is  sure  to 
crack  them. 

Crumbs  in  a  bed  constitute  one  of  the  minor  miseries 
of  sickness,  and  can  not  be  too  carefully  looked  out  for. 
There  should  be  a  regular  crumb  hunt  after  each  meal. 
A  bed  well  cared  for  is  evidence  of  a  good  nurse.  From 
neglect  or  ignorance  of  its  proper  management  very 
serious  consequences  may  arise  in  the  form  of  bed-sores. 
These  result  from  continued  pressure  upon  prominent 
parts  of  the  body,  and  may  vary  in  degree  from  slight 
abrasions  of  the  skin  to  deep  wounds.  They  appear 
most  frequently  upon  the  lower  part  of  the  back,  the 
hips,  shoulders,  elbows,  or  heels,  but  may  develop  wher- 
ever the  conditions  are  favorable.  There  is  liability  to 
them  in  all  cases  of  long  confinement  to  the  recumbent 
posture,  especially  where  the  vitality  is  much  lowered 
— as  in  paralysis,  fevers,  and  old  age.  Very  heavy  and 
much  emaciated  patients  are  alike  predisposed  to  them, 
and  they  are  among  the  most  trying  complications  of 


40  A  TEXT-BOOK  OF  NURSING 

surgical  cases,  where  motion  is  restricted.  Bed-sores 
are  frequently  occasioned  by  bad  nursing,  and  the  cases 
are  rare  in  which  a  good  nurse  can  not  avert  their 
formation.  They  are  more  easily  prevented  than  cured 
when  once  established.  Preventive  measures  consist  in 
keeping  the  parts  thoroughly  clean,  and  the  surface 
under  them  dry  and  smooth,  in  hardening  the  skin,  and 
in  relieving  so  far  as  possible  the  local  pressure.  This 
precautionary  treatment  should  be  commenced  at  the 
beginning  of  any  long  sickness,  without  waiting  for 
manifest  signs  of  danger.  The  parts  most  subjected  to 
pressure  must  be  frequently  washed  with  soap  and  water 
and  thoroughly  dried.  A  draw-sheet  should  be  placed 
under  the  patient,  which  must  be  changed  as  often  as  it 
becomes  damp  from  any  cause,  and  the  greatest  pains 
must  be  taken  to  keep  it  free  from  wrinkles,  crumbs, 
and  inequalities  of  any  kind.  The  patient's  clothes 
must  not  be  permitted  to  form  folds  or  creases  under 
him.  The  skin  may  be  hardened  by  bathing  it  several 
times  daily  with  alcohol,  brandy,  or  eau-de-Cologne,  or 
a  solution  of  bichloride  of  mercury  in  alcohol,  two 
grains  to  the  ounce.  Salt  in  whisky,  two  drachms  to 
the  pint,  and  the  dilute  solution  of  sub-acetate  of  lead, 
are  also  good.  Follow  this  treatment  by  rubbing  in 
well  a  small  quantity  of  some  simple  ointment,  to  keep 
the  skin  supple.  Finally,  dust  the  parts  with  some  fine 
powder,  to  absorb  the  moisture  of  the  skin.  Oxide  of 
zinc  is  perhaps  the  best.  Lycopodium  powder  is  very 
fine  and  soft,  but  has  the  disadvantage  of  staining  the 
bedding.  It  must  be  borne  in  mind  also  that  it  is 
highly  inflammable,  and  must  not  be  used  in  the  vicin- 
ity of  a  lamp.  Fine  starch  or  the  ordinary  toilet  pow- 
der used  for  infants  will  answer,  or  corn-starch,  if  there 
is  nothing  else  at  hand.  If  the  skin  is  intact,  but  red 


BED-SORES  41 

and  angry  in  appearance,  paint  the  spot  thoroughly 
with  nitrate  of  silver,  twenty  grains  to  the  ounce. 

When  the  danger  is  extreme,  or  the  skin  is  already 
abraded,  it  may  be  protected  by  covering  it  with  strips 
of  soap-plaster,  or  by  the  application  with  a  broad  brush 
of  a  single  coat  of  flexible  collodion.  A  thin  layer  of 
absorbent  cotton  with  collodion  poured  over  it  makes 
a  comfortable  and  lasting  covering.  The  greatest  care 
must  be  taken  to  keep  the  part  from  being  pressed  upon. 
The  pressure  may  be  relieved  by  frequent  changes  of 
position,  when  such  are  practicable,  by  circular  pads 
or  air-cushions,  or,  where  the  tendency  is  very  marked, 
by  the  use  of  a  water-bed.  The  latter  equalizes  the 
pressure,  and  is,  in  case  of  paralysis,  or  prolonged  in- 
continence of  urine,  the  only  efficient  safeguard. 

The  first  symptom  of  a  bed-sore  evident  to  the  pa- 
tient is  usually  a  pricking  sensation,  or  a  feeling  as  if 
he  were  lying  on  something  rough.  Or  there  may  be  no 
subjective  indication  whatever.  A  patient  may  be  de- 
lirious, paralyzed,  or  too  weak  to  complain,  and  a  bed- 
sore be  far  advanced  before  it  is  discovered,  unless  con- 
stant vigilance  has  been  exerted  in  this  direction.  On 
this  account  daily  and  careful  examination  should  be 
made  of  such  parts  as  are  especially  subjected  to  pres- 
sure, and  the  first  discovery  of  reddening  or  roughen- 
ing of  the  skin,  or  of  pain  on  pressure,  should  be  ac- 
cepted as  a  warning  of  serious  import.  If  these  symp- 
toms pass  unnoticed  or  uncared  for,  the  discoloration 
will  become  deeper,  and  the  inflammation  progress  until 
sloughing  ensues. 

After  a  bed-sore  is  actually  formed,  its  treatment 
belongs  properly  in  the  province  of  the  surgeon,  but  it 
is  often  delegated  to  the  nurse.  After  the  skin  is 
broken  it  is  customary  to  discontinue  the  use  of  spirit, 


42  A  TEXT-BOOK  OF  NUKSINQ 

as  it  causes  pain,  and  to  dress  with  oxide-of-zinc  oint- 
ment or  iodof  orm.  A  mixture  of  tannic  acid  and  oxide 
of  zinc,  a  scruple  of  each,  worked  up  into  an  ointment 
with  an  ounce  of  vaseline,  is  sometimes  recommended. 
Before  applying  either  of  these  the  wound  should  be 
well  washed  with  a  solution  of  bichloride  of  mercury 
1  to  5,000,  either  by  means  of  a  syringe  or  a  swab. 
Finally,  cover  with  a  good-sized  piece  of  soap-plaster, 
having  the  edges  deeply  cut,  so  that  it  will  be  pliable. 
When  a  slough  has  formed,  its  separation  is  hastened 
by  the  use  of  charcoal  or  chlorinated  poultices.  As  it 
becomes  detached,  it  almost  invariably  reveals  greater 
extent  of  injury  than  its  superficial  appearance  would 
have  led  one  to  anticipate,  often  laying  bare,the  deeper 
tissues  even  to  the  bone.  Poulticing  should  not  be  con- 
tinued longer  than  is  necessary  to  remove  the  gangre- 
nous portion,  as  it  tends  to  soften  and  break  down  the 
neighboring  parts. 

Brown-Sequard  advised  alternate  applications  of 
heat  and  cold,  an  ice-bag  for  ten  minutes,  followed  by  a 
warm  poultice  for  an  hour.  After  the  separation  of  the 
slough,  the  resulting  ulcerated  surface  is  treated  with 
some  stimulating  and  disinfecting  remedy,  as  balsam  of 
Peru,  tincture  of  catechu,  or  carbolic  acid  1  to  40,  ap- 
plied on  lint,  only  within  the  limits  of  the  sore.  An 
excellent  application  at  this  stage  is  that  known  as 
Wood's  mixture,  consisting  of  equal  parts  of  powdered 
catechu,  red  cinchona  and  gum  camphor,  mixed  into  a 
thin  paste  with  balsam  of  Peru.  This  makes  an  indeli- 
ble stain.  Tannic  acid  also  stains.  Iodof  orm,  either  in 
powder  or  in  the  form  of  an  ointment,  may  be  used. 
Cover  the  lint  with  a  piece  of  oiled  muslin  or  rubber 
tissue,  of  a  little  larger  size,  and  confine  the  dressing  in 
place  by  adhesive  strips,  not  by  bandages.  It  must  be 


BED-SORES  43 

renewed  at  least  once  a  day,  and  the  surface  of  the  sore 
washed  with  some  disinfectant  solution  before  it  is  re- 
applied.  Remove  all  pressure  by  circular  pads.  The 
patient's  strength  must  be  supported,  and  the  circula- 
tion improved  as  far  as  possible,  as  the  immediate  cause 
of  bed-sores  is  defective  nutrition.  Regular  massage  of 
the  tissues  about  the  part  injured,  may  help  to  im- 
prove their  tone.  If  neglected,  the  result  may  be  fatal, 
as  the  constant  discharge  may  prove  too  great  a  drain 
upon  an  already  debilitated  patient,  or  pyaemia  may 
supervene  from  the  absorption  of  septic  matter  into 
the  blood. 

"Politeness  is  like  an  air-cushion;  there  may  be  nothing  sub- 
stantial in  it,  but  it  eases  our  jolts  wonderfully." 


CHAPTEK   IV 

"  Deeds  are  the  pulse  of  Time,  his  beating  life, 
And  righteous  or  unrighteous,  being  done 
Must  throb  in  after-throbs  till  Time  itself 
Be  laid  in  stillness,  and  the  universe 
Quivers  and  breathes  upon  no  minor  more." 

George  Eliot. 

IN  view  of  the  definition  of  health  which  we  have 
quoted — the  perfect  circulation  of  pure  Hood  in  a  sound 
organism — it  becomes  desirable  for  us  to  know  some- 
thing of  the  nature  of  pure  blood,  and  of  the  means  by 
which  its  circulation  is  carried  on.  It  is  the  most  abun- 
dant as  well  as  the  most  important  fluid  of  the  body, 
pervading  nearly  every  part  of  the  system;  upon  its 
presence  and  its  unceasing  motion  life  as  well  as  health 
depends.  It  appears  to  the  naked  eye  as  a  simple  red 
fluid,  but  when  examined  under  the  microscope  it  is  seen 
to  be  made  up  of  a  multitude  of  little  solid  bodies  float- 
ing in  a  clear  colorless  liquid.  They  are  called  corpus- 
cles, literally  little  bodies,  and  the  liquid  in  which  they 
float  is  known  as  plasma.  The  plasma  is  made  up  of 
serum  and  fibrin.  The  corpuscles  are  mostly  of  a  yellow- 
ish-red hue,  and  it  is  from  their  vast  numbers  that  the 
blood  derives  its  red  appearance.  There  are  some  white 
ones;  they  are  larger  than  the  red,  and  of  a  different 
shape,  but  are  comparatively  few  in  number. 

The  blood  while  it  circulates  through  the  body  is, 
though  somewhat  glutinous,  perfectly  fluid,  but  upon 
44 


CIRCULATION 


45 


removal  from  its  natural  surroundings  it  exhibits  a  well- 
known  tendency  to  coagulate  or  solidify.  The  fibrin  of 
the  plasma  separates  itself  from  the  serum  and  entan- 
gles the  floating  corpuscles  into  a  mass.  This  peculiar- 
ity affords  protection  against  undue  loss  of  blood,  for 


Red  and  white  corpuscles  of  the  blood.    Magnified. 


dangerous  haemorrhage  would  follow  even  a  slight  cut 
did  not  the  clots  thus  formed  effectually  close  the  in- 
jured blood-vessels  and  prevent  further  escape  of  the 
vital  fluid.  Occasionally  this  coagulation  of  the  fibrin 
takes  place  while  the  blood  is  still  in  motion  through 
the  vessels,  obstructing  the  circulation  very  seriously. 
This  is  called  thrombosis.  A  clot  so  formed  is  called  a 
"  thrombus,"  and  when  detached  and  carried  into  a  dis- 
tant artery  or  capillary  stopping  the  flow  of  blood 
through  the  vessel,  it  constitutes  an  "  embolus." 

The  office  of  the  blood  is  to  convey  nutrition  to  all 


46 


A  TEXT-BOOK  OP  NURSING 


parts  of  the  body,  and  to  remove  its  waste  material. 
The  process  is  carried  on  by  means  of  the  heart  and 
blood-vessels  of  three  distinct  kinds — arteries,  which 
carry  the  blood  away  from  the  heart,  veins,  which  bring 
it  back  to  the  heart,  and  capillaries,  connecting  the 
two. 

The  heart  is  a  pyramidal  organ,  situated  a  little  to 
the  left  of  the  center  of  the  chest.    The  apex,  pointing 

downward,  forward, 
and  to  the  left,  can 
be  felt  between  the 
fifth  and  sixth  ribs. 
The  base  is  on  a 
level  with  the  upper 
border  of  the  third 
rib.  The  base  is 
fixed,  but  the  apex  is 
freely  movable.  The 
heart  is  composed  of 
muscular  fiber.  It  is 
enveloped  in  a  fibro- 
serous  membrane, 
called  the  pericardi- 
um, which  secretes  a 
lubricating  fluid  en- 
abling its  movements 
to  be  accomplished 
without  loss  of  power 
by  friction.  It  is  hollow,  and  is  partitioned  into  four 
cavities  or  chambers,  of  nearly  equal  capacity,  two 
at  the  base  called  auricles,  and  two  below  termed 
ventricles.  There  is  no  opening  between  the  ven- 
tricles. A  valve  between  the  two  auricles  closes 
at  birth  and  gradually  disappears,  after  which  there 


Heart  and  large  blood-vessels. 


CIRCULATION  4T 

is  no  longer  any  connection  between  the  two  sides 
of  the  heart.  The  left  side  always  contains  pure, 
the  right  side  impure,  blood.  If  the  valve  between 
the  two  auricles  fails  to  close  when  independent 
circulation  is  established,  or  soon  after,  the  impure 
blood  mixes  with  the  pure,  giving  the  skin  a  blue 
tinge.  A  child  in  this  condition  is  called  a  <(  blue  baby," 


Cavities  of  the  heart :  ra,  right  auricle ;  rv,  right  ventricle ;  la,  left  auricle; 
Iv,  left  ventricle.    The  arrows  indicate  the  course  of  the  blood. 

and  rarely  lives  long.  But  between  each  auricle  and  its 
corresponding  ventricle  there  is  an  orifice,  guarded  by 
a  valve,  which  permits  the  passage  of  fluid  in  but  one 


48  A  TEXT-BOOK  OF  NURSING 

direction — downward.  The  valve  between  the  right 
auricle  and  the  right  ventricle  is  called  the  tricuspid 
valve;  that  at  the  left  auriculo-ventricular  aperture, 
the  bicuspid,  or,  more  commonly,  the  mitral  valve. 
Each  ventricle  has  also  another  opening,  provided  with 
a  set  of  "  semilunar  "  valves,  connecting  it  with  a  large 
artery,  the  aorta  on  the  left,  and  the  pulmonary  on  the 
right.  The  auricles  also  have  other  openings  through 
which  the  blood  flows  into  them  from  the  great  veins, 
but  they  are  not  supplied  with  valves.  As  the  auricles 
become  filled,  they  contract,  and  the  blood,  following 
the  line  of  least  resistance,  is  forced  into  the  ventricles. 
They  in  turn  similarly  contract,  forcing  it  on  into  the 
arteries,  regurgitation  being  in  each  case  prevented  by 
the  intervening  valves.  The  sounds  heard  upon  auscul- 
tation are  produced  by  the  closing  of  these  valves. 
Then  follows  a  pause,  after  which  the  contractions  are 
repeated  in  the  same  order,  and  are  followed  again  by 
the  same  period  of  repose,  during  which  the  cavities  un- 
dergo gradual  dilatation.  The  pause  occupies  about  as 
much  time  as  the  two  contractions,  the  entire  action  less 
than  one  second.  The  state  of  contraction  of  the  ven- 
tricle, or  auricle,  is  called  its  systole,  that  of  relaxa- 
tion its  diastole.  Both  sides  of  the  heart  act  simul- 
taneously. 

Let  us  follow  on  its  course  the  blood  which  is  ex- 
pelled by  the  left  ventricle.  The  semilunar  valves  open 
to  allow  it  to  pass  into  the  aorta,  the  main  trunk  of  the 
arteries.  This  ascends  from  the  upper  part  of  the  left 
ventricle  for  a  short  distance,  then  forms  an  arch  back- 
ward over  the  root  of  the  left  lung,  and  passes  down 
into  the  abdomen,  where  it  is  divided  into  two  great 
branches.  In  every  part  of  it's  course  it  sends  out  simi- 
lar branches  on  each  side.  These  all  divide  and  subdi- 


CIRCULATION 


vide  into  numberless  ramifications,  extending  to  all 
parts  of  the  body,  and  gradually  diminishing  in  size  as 
they  become  more  and  more  remote  from  the  heart. 
The  blood  receives  an  impulse  from  the  ventricular 
systole,  which  sends  it  through  the  entire  arterial  sys- 
tem. The  minute  branches  of  the  arteries  empty  their 
contents  finally  into  an  even  smaller  set  of  vessels 
known  as  capillaries.  To  call  them  hair-like  is,  how- 
ever, an  exaggeration,  for  they  are  so  fine  as  to  be 
invisible  to  the  naked  eye ;  still  they  serve  for  the  trans- 
mission of  the  microscopic  blood-corpuscles.  They  in- 
terlace in  every  direc- 
tion, making  an  elab- 
orate network,  and 
finally  unite  to  form 
blood-vessels  of  the 
third  order,  the  veins, 
which  carry  the  blood 
back  to  the  heart. 
These  are  at  first  ex- 
tremely small,  but,  by 
constantly  running  to- 
gether, they  increase 
in  size  as  they  ad- 
vance, until  they  final- 
ly all  combine  into  two 
great  trunks,  the  su- 
perior and  inferior 
venae  cavae,  which 

empty  into  the  right  auricle  of  the  heart.  The 
veins  returning  to  the  heart  follow  closely  in  the  track 
of  the  arteries  which  lead  away  from  it,  but  they  lie 
nearer  the  surface. 

The  smallest  arteries  and  veins  are  quite  similar  in 


Diagram  of  the  course  of  the  blood. 


50  A  TEXT-BOOK  OF  NURSING 

structure,  but  the  larger  ones  have  numerous  points  of 
difference.  The  walls  of  the  arteries  are  composed  of 
three  coats,  an  outer  one  of  strong  connective  tissue, 
a  smooth  inner  lining,  a  continuation  of  the  endocar- 
dium, the  lining  membrane  of  the  heart ;  between  these 
is  a  layer  which  in  the  largest  arteries  consists  of  elastic 
tissue,  in  those  of  lesser  caliber  of  elastic  and  muscular 
fibers,  and  in  the  smallest  of  the  muscular  fibers  alone. 
It  follows  that  the  largest  arteries  have  the  most  elas- 
ticity, and  the  smallest  the  most  highly  contractile 
power.  Their  walls  have  sufficient  firmness  to  retain 
their  cylindrical  form  even  when  empty.  They  are 
always  found  empty  after  death.  Veins,  on  the  other 
hand,  are  less  elastic,  have  thinner  walls,  and  collapse 
when  empty.  Many  of  the  veins  are  supplied  with 
valves,  which  permit  the  flow  of  blood  only  toward  the 
heart.  The  capillaries  are  less  complex  than  the  other 
blood-vessels,  consisting  of  but  a  single  membrane,  and 
that  so  thin  that  their  fluid  contents  readily  exude. 
The  velocity  of  the  blood  decreases  as  it  approaches 
the  capillaries,  its  progress  being  delayed  by  the  nar- 
rowness and  intricacy  of  the  path  it  has  to  travel.  Time 
is  thus  allowed  for  the  assimilation  of  the  nutrient 
portion  of  the  blood  by  the  living  tissues  with  which  it 
is  here  brought  into  intimate  contact.  As  it  enters  the 
veins  its  motion  is  again  somewhat  accelerated,  though 
it  never  regains  the  speed  with  which  it  rushes  through 
the  arteries.  Having  once  completed  the  circuit  of 
arteries,  capillaries  and  veins,  the  blood  is  restored  to 
the  heart  and  its  general  or  systemic  circulation  is  com- 
plete. It  has,  however,  undergone  a  change  in  char- 
acter and  appearance  during  its  stay  in  the  capillaries ; 
some  of  its  elements  have  been  appropriated,  it  has 
become  charged  with  waste  matter,  and  has  lost  its 


CIRCULATION  51 

bright  color.  Before  it  is  fit  for  further  use  it  must  be 
purified  and  renewed.  To  accomplish  this,  and  to  re- 
turn to  that  side  of  the  heart  from  which  it  started,  it 
has  another  journey  to  take.  This,  to  distinguish  it 
from  the  former,  is  spoken  of  as  the  lesser,  or  pulmo- 
nary circulation.  From  the  right  auricle,  into  which  it 
is  poured  by  the  vena  cava,  the  tricuspid  valve  allows 
the  blood  to  flow  into  the  right  ventricle,  the  next  con- 
traction of  which  forces  it  by  the  pulmonic  semilunar 
valves  into  the  pulmonary  artery,  which  leads  to  the 
lungs.  This,  like  all  the  other  arteries,  is  subdivided 
into  numerous  small  branches,  and  finally  establishes 
connection  with  a  set  of  capillaries.  In  the  pulmonary 
capillaries  the  blood  is  brought  into  close  relation  with 
the  inspired  air,  and  undergoes  a  process  of  renovation. 
The  pulmonary  veins  then  carry  it  back  to  the  left 
auricle,  ready  to  start  again  upon  its  double  circulation. 
It  will  be  seen  that  in  the  pulmonary  system  of  circu- 
lation the  general  arrangement  is  so  far  reversed  that 
the  arteries  become  the  bearers  of  the  impure,  and  the 
veins  of  the  pure  blood. 

The  blood-vessels,  branching  in  every  direction, 
communicate  in  all  parts  of  the  body,  so  that,  if  the 
main  course  of  the  blood  is  interrupted,  it  may  still  go 
on  its  way  by  making  a  detour  through  minor  rami- 
fications. Such  communication  of  vessels  is  called 
anastomosis.  The  collateral  circulation  which  it  allows 
is  of  great  surgical  value,  permitting  a  large  artery  to 
be  tied  without  obstructing  the  general  circulation. 

When  a  larger  amount  of  blood  than  is  natural  is 
sent  to  any  part  the  condition  is  called  congestion.  The 
blood-vessels  enlarge  somewhat  to  let  the  increased  sup- 
ply of  blood  through,  but  the  tissues  can  not  take  up 
the  excess  of  fibrin,  and  the  capillaries  become  clogged, 


52  A  TEXT-BOOK  OF  NURSING 

causing  a  stoppage  or  stasis.  In  this  state  of  things 
the  fibrin  oozes  out  of  the  blood-vessels  into  the  tissues 
and  is  deposited  in  a  more  or  less  solid  mass.  This 
is  known  as  exudation  of  plastic  lymph.  The  congested 
condition  may  gradually  disappear,  and  the  blood  re- 
sume its  normal  flow  after  merely  temporary  stasis. 
This  is  termed  resolution.  The  excess  of  fibrin  is  not, 
however,  always  reabsorbed,  but  remains  outside  the 
blood-vessels  causing  perceptible  thickenings.  These 
are  adhesions.  Exudation  of  plastic  lymph  takes  place 
only  when  arterial  blood  is  obstructed.  If  there  is 
stasis  of  venous  blood,  we  have  an  exudation  of  serum, 
which  is  dropsy.  If  the  determination  of  blood  to  the 
part  is  not  soon  relieved  inflammation  ensues.  A  large 
proportion  of  all  diseases,  medical  or  surgical,  are  in- 
flammatory at  some  time  in  their  course.  Disease  is 
always  the  result  of  impaired  nutrition,  and  inflamma- 
tion has  been  described  as  misdirected  nutrition.  It  is 
.characterized  by  heat,  swelling,  redness,  pain,  and  exu- 
dation of  serum.  It  may  terminate  by  resolution,  or 
by  suppuration.  In  the  latter  case  the  white  corpuscles 
work  their  way  out  of  the  blood-vessels  and  multiply 
in  the  plastic  lymph,  producing  pus.  When  small  por- 
tions of  tissue  die  from  their  supply  of  nutriment  being 
cut  off  we  have  ulceration.  Death  of  a  large  mass  of 
tissue  is  gangrene.  The  character  of  an  inflammation 
and  its  treatment  depend  upon  its  location  and  its 
extent. 

Each  contraction  of  the  heart  sends  out  a  wave 
which  distends  the  blood-vessels,  and  which  they,  by 
their  elasticity,  carry  on  through  the  entire  arterial 
system.  This  intermittent  distention  of  the  arteries 
is  known  as  the  pulse.  It  corresponds  with  the  systolic 
action  of  the  heart,  and  is  characteristic  of  the  arterial 


PULSE  53 

flow,  being  absent  from  the  venous.  Wherever  an  ar- 
tery approaches  the  surface,  the  pulse-beats  can  be  felt 
and  counted.  The  pulse  is  a  valuable  guide  in  disease, 
as  it  varies  with  the  condition  of  the  heart,  and  affords 
an  accurate  index  of  its  action.  It  is  usually  taken, 
for  convenience,  at  the  radial  artery,  just  above  the 
wrist ;  if  it  becomes  imperceptible  there,  it  may  perhaps 
still  be  felt  at  the  temporal,  femoral,  or  carotid,  as 
large  arteries  retain  their  pulsation  longest.  In  chil- 
dren, you  may  feel  it  best  in  the  temporal  artery  during 
sleep.  It  is  often  difficult  to  feel  a  child's  pulse  any- 
where when  it  is  awake. 

To  take  the  pulse  accurately,  place  two  or  three  fin- 
gers along  the  course  of  the  artery,  making  slight  pres- 
sure, and  count  for  a  full  minute,  by  tens,  with  inter- 
vals of  ten  seconds  between  counts.  The  rate  varies 
with  varying  circumstances.  Age,  sex,  food,  tempera- 
ture, position,  exertion,  mental  states,  and  many 
other  conditions  modify  it  even  in  health.  It  is  usu- 
ally more  rapid  in  women  than  in  men,  in  children  than 
in  adults.  It  is  slow  during  sleep,  quicker  after  taking 
food,  more  rapid  standing  than  sitting,  and  sitting  than 
lying  down.  The  average  rate  in  a  healthy  adult  is  72 
beats  per  minute;  in  a  child,  from  105  to  120  for  the 
first  twelve  months  of  life,  to  from  80  to  90  during  the 
period  from  seven  to  ten  years.  Considerable  vari^ 
ations  from  this  standard  may,  however,  be  compat- 
ible with  health.  Individuals  differ  so  much  that  a 
pulse  which  would  be  quite  alarming  in  one  subject 
might  mean  nothing  wrong  in  another. 

Nearly  all  abnormal  conditions  of  the  body  have 

some  effect  upon  the  pulse.     Increase  in  the  rate  is 

more  common  than  diminution.    The  character,  as  well 

as  the  frequency,  is  subject  to  variations.    In  a  quick 

5 


54  A  TEXT-BOOK  OP  NURSING 

pulse,  each  beat  occupies  less  than  the  usual  time — that 
is,  each  wave  is  of  short  duration  relatively  to  the  pause 
between.  When  the  volume  of  the  pulse  is  greater  than 
usual,  it  is  said  to  be  large  or  full;  if  less  than  usual, 
small.  When  the  pulse  can  be  easily  stopped,  it  is  said 
to  be  compressible;  incompressible  when  it  can  only  be 
arrested  with  difficulty,  or  not  at  all.  In  an  irregular 
pulse,  succeeding  beats  differ  in  length,  force,  and  char- 
acter. In  an  intermittent  pulse,  a  beat  is  now  and  then 
lost,  the  rhythm  being  otherwise  regular.  The  inter- 
mittency  may  occur  at  regular  intervals,  as  every  tenth 
or  twentieth  beat  may  be  lost,  or  it  may  be  without  any 
regularity.  An  intermittent  pulse  is  occasionally  ob- 
served in  persons  otherwise  healthy.  It  is  always  a  less 
serious  symptom  than  an  irregular  one.  Other  depar- 
tures from  the  normal  standard  are  variously  described 
as  hard  or  soft,  sharp,  jerking,  bounding,  throbbing, 
spotty,  thready,  wiry,  flickering,  undulatory,  etc.,  the 
names  of  which  sufficiently  explain  their  effect  to  the 
touch.  In  the  dicrotic  pulse,  a  secondary  wave  of  oscil- 
lation becomes  exaggerated  so  as  to  be  felt.  An  inex- 
perienced person  may  mistake  this  for  the  primary 
wave,  and  so  be  led  to  count  double  the  real  number  of 
beats.  This  pulse  is  often  met  in  typhoid  fever.  In 
some  cases  the  pulse  in  the  two  wrists  will  be  different, 
and  rarely  it  can  be  felt  in  one  wrist  only.  When  the 
beat  occurs  a  little  later  in  one  radial  artery  than  in 
the  other  it  is  said  to  be  retarded;  this  usually  indicates 
aneurism. 

The  blood  has  still  another  function,  that  of  keeping 
the  body  warm.  Animal  heat  is  generated  by  continual 
chemical  change,  in  which  the  blood  is  an  active  agent. 
The  bodily  temperature  in  health  remains  nearly  the 
same,  about  98.6°  F.,  in  spite  of  the  variations  of  the 


TEMPERATURE  55 

external  temperature.  The  action  of  the  skin  keeps 
the  heat  from  accumulating,  and  the  arteries,  under  the 
influence  of  the  nervous  system,  dilate  or  contract,  and 
so  assist  in  maintaining  the  equilibrium  by  altering  the 
rate  of  production  to  correspond  with  the  loss  of  heat. 
Life  is  secure  so  long  as  the  production  and  the  escape 
of  heat  are  evenly  balanced. 

There  is  a  definite  daily  cycle  of  variations,  amount- 
ing to  one  or  two  degrees.  According  to  Quain,  the 
temperature  of  a  healthy  adult  reaches  its  highest  point 
between  5  and  8  P.  M.,  and  is  at  its  lowest  from  2  to  6 
A.  M.  A  deviation  of  more  than  one  degree  from  the 
normal  standard,  that  is,  above  99£°,  or  below  97£°,  may 
be  regarded  as  indicative  of  disease.  There  is  only  a 
range  of  about  twenty  degrees  within  which  life  can 
be  sustained.  A  temperature  above  108°,  or  below  93°, 
will  in  most  cases  prove  fatal.  The  danger  is  in  pro- 
portion to  the  distance  from  the  normal,  and  to  the 
length  of  time  that  the  condition  continues.  Tempera- 
ture below  the  normal  standard  is  far  more  dangerous 
than  the  same  number  of  degrees  above,  as  the  follow- 
ing table  shows : 

Hyperpyrexia 106°,  and  over,  extremely  dangerous. 

High  fever 103$°— 106°. 

Moderate  fever 101°  —103^°. 

Subfebrile 994°— 101°. 

Normal 98°  — 99£°. 

Subnormal 97°  —98°. 

Collapse 95°  —97°. 

Algid  collapse .  .below  95°  — again  extremely  dangerous. 

Very  high  temperatures  sometimes  occur  in  hysteria 
without  danger. 

Most,  though  not  all,  morbid  states  are  accompanied 
by  alterations  in  temperature,  some  of  which  are  so 


56  A  TEXT-BOOK  OP  NURSING 

typical  as  to  be  of  great  diagnostic  value.  Rise  of 
temperature  above  99£°  constitutes  fever,  or  pyrexia. 
It  is  occasioned  either  by  imperfect  loss  of  heat  or  by 
overproduction.  The  amount  of  heat  produced  is  pro- 
portional to  the  activity  of  respiration  and  the  amount 
of  oxygen  consumed.  The  pulse  is  generally  accelerated 
in  proportion  to  the  elevation  of  temperature,  though 
the  proportion  varies  in  different  diseases.  In  scarlet 
fever,  for  instance,  the  pulse  will  be  quicker  than  in 
typhoid  with  the  same  temperature.  If  the  pulse  is 
more  rapid  than  the  temperature  will  explain,  it  indi- 
cates cardiac  weakness. 

A  change  of  temperature  may  be  the  first  symptom 
of  disorder,  occurring  even  before  indisposition  is  felt. 
It  is  of  importance  to  get  this  first  variation  from  the 
normal  temperature ;  and  as  medical  advice  is  not  likely 
to  be  called  for  until  more  evident  symptoms  have 
manifested  themselves,  every  mother  as  well  as  every 
nurse  ought  to  own  a  clinical  thermometer,  and  to 
know  how  to  use  and  read  it.  She  can  do  no  harm,  and 
she  may  do  a  great  deal  of  good,  by  using  it  upon  the 
first  suspicion  of  a  departure  from  health.  A  slight 
variation  from  the  normal  is  of  less  serious  import  in 
a  child  than  in  an  adult,  unless  it  is  found  to  be  increas- 
ing. An  increase,  beginning  each  day  a  little  earlier, 
is  a  bad  indication ;  a  decrease  from  a  high  temperature, 
beginning  each  day  earlier,  is  a  sign  of  improvement. 
The  daily  fluctuations  take  place  also  in  disease,  and 
are  sometimes  much  exaggerated.  Sometimes  fever  is 
continuously  high,  with  only  the  normal  amount  of 
variation;  or  it  may  be  remittent,  that  is,  with  a  wide 
range  between  its  highest  and  lowest  points,  though 
never  sinking  to  normal ;  or  intermittent,  in  which  type 
the  temperature  alternately  rises  to  febrile  height  and 


TEMPERATURE  57 

falls  to  or  below  the  normal.  In  some  disorders,  as 
pneumonia,  and  others  similarly  initiated  with  a  chill, 
the  rise  will  be  rapid  and  sudden;  in  others  there  will 
be  at  first  but  slight  elevation,  which  gradually  in- 
creases. Typhoid  is  of  the  latter  class,  the  temperature 
rising  about  two  degrees  daily,  but  falling  again  each 
morning,  so  that  the  maximum  mark  is  only  reached 
on  the  fifth  or  sixth  day.  A  febrile  temperature  may 
be  expected  to  rise  toward  evening,  but  in  rare  cases  the 
ordinary  rule  will  be  reversed,  and  there  will  be  rise 
in  the  morning  and  remission  in  the  evening.  In  some 
cases  of  typhoid  and  phthisis  two  exacerbations  have 
been  observed  in  the  twenty-four  hours,  with  two  dis- 
tinct remissions.  Such  deviations  can  only  be  recog- 
nized by  testing  the  temperature  frequently.  It  will  be 
evident  that  isolated  observations  have  not  the  value 
of  a  regular  series.  The  temperature  should  be  taken 
at  the  same  hour  each  day  to  exhibit  accurately  the 
cycle  of  fluctuations.  An  irregularity  in  temperature, 
in  the  course  of  a  disease  which  has  usually  a  regular 
type,  is  indicative  of  some  complication.  Or  it  may  de- 
pend upon  local  causes,  and  may  be  improved  with 
them.  Thus  constipation  will  often  send  up  the  tem- 
perature, which  will  fall  again  after  its  relief.  Bad 
air  may  have  the  same  effect.  The  decline  of  fever,  or 
defervescence,  may,  like  the  rise,  be  gradual  from  day 
to  day,  or  sudden,  dropping  to  a  steady  normal  in  from 
six  to  thirty-six  hours.  The  former  is  said  to  be  by 
lysis,  the  latter  through  a  crisis. 

Temperature  may  be  artificially  reduced  by  applica- 
tions of  cold,  or  by  antipyretic  medicines;  it  may  be 
brought  up  by  external  heat  and  stimulants.  The 
former  act  most  effectively  at  the  times  when  the  tem- 
perature has  a  natural  tendency  to  fall,  and  the  latter 


58  A  TEXT-BOOK  OP  NURSING 

when  the  tendency  is  to  rise,  as  the  effort  of  nature  is 
then  assisted  rather  than  opposed. 

Any  great  modification  of  temperature  is  usually 
recognizable  to  the  touch,  but  to  measure  its  extent 
with  mathematical  certainty  the  clinical  thermometer 
is  used.  This  now  familiar  little  instrument  is  indis- 
pensable to  every  nurse.  Before  use  the  index  must  be 
thrown  down  to  a  point  two  or  three  degrees  below  the 
normal.  Hold  it  with  the  bulb  down,  and  shake  until 
the  mercury  falls.  Do  not  shake  it  so  hard  as  to  force 
all  the  mercury  into  the  bulb. 

The  temperature  may  be  taken  under  the  tongue, 
in  the  axilla,  groip,  rectum,  or  vagina.  The  tempera- 
ture of  the  interior  of  the  body  is  more  even,  and  some- 
what more  elevated,  than  that  of  the  surface,  so  that, 
when  it  is  taken  in  either  of  the  natural  cavities,  the 
index  will  reach  a  point  at  least  half  a  degree  higher 
than  in  an  artificial  cavity.  The  mouth  will  be  a  little 
cooler  than  the  cavities  constantly  closed,  and  the  axil- 
lae cooler  still,  and  it  will  take  longer  time  for  the  mer- 
cury to  rise  in  these  places,  unless  the  precaution  has 
been  taken  to  keep  the  mouth  or  axilla  previously 
closed  for  ten  minutes,  that  they  may  have  assumed  a 
steady  temperature.  A  little  time  may  be  saved  by 
slightly  warming  the  bulb  in  the  hand  before  its  intro- 
duction. Keep  the  patient  well  covered  for  some  little 
time  before  taking  an  axillary  temperature.  The  part 
should  not  have  been  exposed  for  washing  or  dressing 
for  at  least  half  an  hour  previously.  The  axilla  must 
be  first  dried  from  perspiration,  care  be  taken  that 
the  clothing  is  not  in  the  way,  and  the  thermometer 
held  firmly  in  position.  This  is  best  done  by  pressing 
the  arm  closely  to  the  side,  and  flexing  it  till  the  hand 
touches  the  opposite  shoulder.  Where  great  accuracy 


TEMPERATURE  59 

is  needed,  the  thermometer  should  be  left  in  place  until 
the  index  has  remained  stationary  for  five  minutes.  In 
a  very  emaciated  subject  it  may  be  impossible  to  get  a 
correct  axillary  temperature. 

The  temperature  is  frequently  taken  in  the  mouth, 
the  bulb  of  the  thermometer  being  placed  under  the 
tongue.  This  is  not  always  safe,  as  there  is  danger  that 
a  child,  or  an  irresponsible  patient,  may  bite  off  the 
bulb.  The  lips  must  be  kept  closed  during  the  process. 
Do  not  take  the  temperature  in  the  mouth  immediately 
after  a  patient  has  been  eating  ice,  nor  wash  the  ther- 
mometer in  warm  water  before  looking  at  it,  or  you  may 
get  alarming  results. 

The  rectum  gives,  perhaps,  the  most  reliable  tem- 
perature, as  there  are  fewer  possible  sources  of  error. 
This  method  is  always  employed  for  infants.  The  tube 
should  be  oiled  and  inserted  for  nearly  two  inches.  Re- 
member that,  if  the  rectum  contains  faecal  matter,  the 
index  will  not  reach  so  high  a  point  as  if  the  bulb 
conies  directly  in  contact  with  the  mucous  membrane. 

The  length  of  time  required  to  take  a  temperature 
depends  not  only  upon  the  locality  selected,  but  also 
to  some  extent  upon  the  thermometer  used.  Some  will 
do  the  work  in  one  minute,  while  others  take  three  or 
five,  other  things  being  equal.  Every  thermometer  in 
use  ought  to  be  annually  compared  with  some  standard, 
as  after  a  time  it  will  cease  to  register  correctly.  The 
bulb  gradually  contracts  a  little,  and  too  high  indica- 
tions result.  Never  leave  a  thermometer  with  a  patient 
unwatched,  unless  you  are  very  sure  he  is  to  be  trusted 
to  take  care  of  it. 

Inflammation  sometimes  gives  a  local  rise  of  tem- 
perature, without  affecting  the  general  heat  of  the  body. 
To  test  this,  a  surface  thermometer  is  used,  one  with 


60  A  TEXT-BOOK  OF  NURSING 

the  reservoir  flattened,  so  as  to  receive  impressions  from 
the  open  surface.  The  scale  is  the  same  as  that  of  the 
ordinary  fever  thermometer,  divided  into  degrees  and 
fifths,  but  it  is  not  self -registering.  They  usually  come 
in  pairs  matched  to  work  together;  but  this  arrange- 
ment has  only  the  advantage  of  saving  time.  One  will 
answer  every  practical  purpose.  It  is  to  be  applied 
alternately  over  the  seat  of  inflammation,  and  over 
some  corresponding  part  known  to  be  isothermal  with 
it  in  health.  The  difference  shows  the  amount  of 
increase  in  the  local  heat.  This,  like  the  general  tem- 
perature, will  be  found  to  fluctuate,  exhibiting  periods 
of  exacerbation  and  defervescence. 

Temperatures  should  not  only  be  accurately  taken, 
but  correctly  recorded.  Note  the  degree  and  hour  im- 
mediately upon  taking,  without  leaving  time  to  forget. 
Clinical  charts  are  made  to  be  filled  up  with  the  records 
of  temperature ;  lines  drawn  from  point  to  point,  as  the 
rise  and  fall  are  noted,  often  give  very  characteristic 
curves.  The  accompanying  illustration  is  taken  from  a 
tpyhoid  case.  The  corresponding  variations  of  the 
pulse  may  be  shown  on  the  same  chart  by  a  second  set 
of  lines  drawn  in  red  ink. 

The  pulse  and  temperature  should  always  be  con- 
sidered together,  not  separately.  The  pulse  is  a  more 
certain  test  of  the  patient's  condition  than  the  tempera- 
ture. In  peritonitis  a  rapid  pulse  with  low  temperature 
is  often  a  grave  indication.  The  pulse  is  very  rapid  and 
feeble  in  some  patients  when  under  ether,  or  immedi- 
ately after  an  operation  not  necessarily  severe.  This 
needs  to  be  distinguished  from  the  rapid  fluttering  pulse 
after  profuse  haemorrhage. 

Some  of  the  recently  discovered  antipyretics — nota- 
bly antifebrin — may  bring  the  temperature  down  in  two 


oiscm 


19 


DATES     Of   OBSERVATIONS. 


JULY. 


25 


'27 


28 


29 


30 


31 


AUGUST. 


1 


10 


11 


Cat 


fljtr.  AM  '•  PIMM  '.PX  AM  •'  PM  AM  '.  PM  Ul  •  PM  M  -PM  AM  •  PM 


AM.PMAM.PMAM.PM  AM  -PM  AM  •  PMIAM).  PM  AM  .  PM 


AM  .  PM  AM  .  PM  AM  .  PM  AM  .  PM  AM 


1 

'Mill 


r 


_': 


::  : 


-t  :! 


i7 


_. 


DATE'S     Or  OBSERVATIONS. 


H 


15 


16 


17 


18 


20 


21 


22 


23 


24 


25 


26 


28 


29 


30 


31 


SEPTEMBER. 


1 


M  AM .  PM  AM .  PM  AM  .  PM  AM  .  PM  AM  •  PM  AN  -  PM 


AM  -PMAM'. PM  AM'PMAM'.PMAM.'PMAM.'PM  AM*. PHAM^PMAMlpM 


AM.,PMAM'PM  AM!  PM 


AM  .  PM  AM  •  PM  AM  •  PM  AM  .  PM 


A 


L& 


V 


TEMPERATURE  61 

or  three  hours  from  a  high,  to  a  subnormal  point, 
especially  in  children,  who  are  very  susceptible  to  the 
influence  of  drugs.  This  is  not  alarming,  unless  the 
patient  becomes  cyanotic  and  the  pulse  feeble,  but  stim- 
ulants and  hot  bottles  are  indicated. 

"  We  can  not  kindle  when  we  will 

The  fire  that  in  the  heart  resides, 
The  spirit  bloweth  and  is  still, 
In  mystery  our  soul  abides ; 
But  tasks  in  hours  of  insight  willed 
Can  be  through  hours  of  gloom  fulfill'd. " 

M.  Arnold. 


CHAPTEK   V 

"  Like  a  kind  hand  on  my  brow 

Comes  this  fresh  breeze, 
Cooling  its  dull  and  feverish  glow, 
While  through  my  being  seems  to  flow 
The  breath  of  a  new  life — the  healing  of  the  seas ! " 

J.  O.  Whittier. 

WE  have  seen  that  the  blood  undergoes  in  the  lungs 
a  process  of  purification,  rendering  it  fit  for  renewed 
use.  To  understand  how  this  is  accomplished,  one  must 
know  something  of  the  construction  and  working  of  the 
respiratory  organs,  the  chief  of  which  are  the  lungs, 
trachea,  and  muscles  of  the  chest. 

The  lungs  themselves  are  of  a  sponge-like  substance, 
composed  of  air-cells  lined  by  a  network  of  minute 
blood-vessels.  These  blood-vessels  are  the  subdivisions 
of  the  pulmonary  veins  and  arteries.  A  series  of  bron- 
chial tubes  connect  the  air-cells  with  the  external  air, 
those  of  each  lung  uniting  into  a  single  bronchus,  and 
the  two  finally  unite  with  each  other,  to  form  the  tra- 
chea or  windpipe.  Each  lung  is  enveloped  in  a  delicate 
membrane  called  the  pleura.  This  is,  at  the  root  of  the 
lung,  folded  back  so  as  to  form  also  a  lining  to  the 
chest.  It  secretes  a  fluid  which  keeps  it  constantly 
moist,  and  enables  the  two  surfaces  to  slide  easily 
against  each  other. 

The  chest  is  separated  from  the  abdominal  cavity 
by  a  muscular  partition — the  diaphragm — which  alter- 


RESPIRATION 


63 


nately  rises  and  falls,  as  its  fibers  contract  and  relax. 
The  motion  is  involuntary,  but  is  partially  under  con- 
trol. As  the  capacity  of  the  chest  is  increased  by  the 
descent  of  the  diaphragm,  the  additional  space  is  filled 
by  air,  sucked  in  through  the  trachea  and  bronchi,  and 
expanding  the  elastic  cells.  As  the  diaphragm  rises 


The  cavity  of  the  chest,  showing  the  positions  of  the  heart  and  the 
lungs:  A,  left  lung;  B,  heart;  D,  pulmonary  artery;  E,  trachea  or 
windpipe. 

this  extra  supply  of  air  is  forced  out  again.  The  size 
of  the  thoracic  cavity  is  still  further  affected  by  move- 
ments of  the  intercostal  muscles,  which  elevate  and  de- 
press the  ribs.  By  these  muscular  actions,  and  the  con- 
sequent expansion  and  contraction  of  the  lungs,  the 
alternate  inspirations  and  expirations  are  produced 


64  A  TEXT-BOOK  OP  NURSING 

which  we  call  breathing  or  respiration.  The  lungs  are 
not  completely  filled  and  emptied  by  each  respiration; 
a  certain  amount  of  air  is  stationary  in  them.  The 
additional  supply  drawn  in  and  out,  sometimes  called 
tidal  air,  is  but  a  small  proportion  of  the  entire  con- 
tents of  the  lungs ;  but  it  is  diffused  through  and  alters 
the  character  of  the  whole.  At  the  end  of  each  expira- 
tion follows  a  period  of  repose  about  equal  to  the  en- 
tire period  of  action. 

A  healthy  adult  ordinarily  breathes  about  eighteen 
times  per  minute,  taking  in  each  time  some  twenty 
cubic  inches  of  air.  It  takes,  at  this  rate,  sixteen  res- 


Lungs  and  air-passages :  a,  larynx ;  b,  trachea ;  c,  d,  bronchi ;  e,  bronchial 
tubes ;  /,  lobules. 

pirations  to  completely  renovate  the  air  in  the  lungs. 
By  this  gradual  introduction  of  the  outer  air  its  tem- 
perature is  rendered  more  fit  for  contact  with  the  deli- 
cate capillaries,  and  there  is  a  reserve  supply  in  case 
of  any  accidental  embarrassment  of  respiration.  It  is 
worth  noting  that  the  habit  of  taking  deep  inspirations 
increases  the  strength  and  capacity  of  the  lungs. 


RESPIRATION  65 

The  direct  object  of  respiration  is  the  purification 
of  the  blood.  Let  us  see  just  how  this  is  effected. 
The  air  is  a  mechanical  mixture  of  oxygen  and  nitro- 
gen, with  a  small  proportion  of  carbonic-acid  gas  and 
watery  vapor.  Its  average  composition  is  a  little  less 
than  twenty-one  volumes  of  oxygen  to  seventy-nine  of 
nitrogen.  The  nitrogen  in  the  atmosphere  acts  simply 
as  a  diluent.  The  oxygen  is  the  universal  supporter  of 
life,  the  vitalizing  force  of  all  animal  organisms.  Car- 
bonic acid,  on  the  contrary,  is  so  poisonous  a  gas  that 
two  or  three  parts  of  it  in  a  thousand  will  produce 
sensibly  bad  effects — as  headache,  nausea,  and  drowsi- 
ness. Five  per  cent  may  be  fatal. 

The  walls  of  the  air-cells  consist  of  a  mere  film  of 
mucous  membrane,  thin  enough  to  allow  interchange  of 
gases  to  take  place  through  it,  though  impervious  to 
liquids.  Such  transudation  of  fluid  through  a  moist 
animal  membrane  is  known  as  osmosis. 

Oxygen  has  a  stronger  affinity  for  blood  than  for 
nitrogen;  so,  when  it  is  brought  near,  it  leaves  the  air 
inspired,  to  unite  with  the  blood  in  the  lungs.  But  car- 
bonic acid  and  water — both  of  which  are  to  be  found  in 
the  blood — have  greater  affinity  for  air,  and  pass  into  it. 
So  the  air  expired  retains  its  nitrogen,  and  takes  car- 
bonic acid  and  water,  but  loses  a  part  of  its  oxygen. 

The  processes  of  circulation  and  respiration  are  thus 
intimately  connected,  and  whatever  modifies  the  pulse 
affects  also  the  breathing.  There  are  usually  four  beats 
of  the  pulse  to  every  respiration.  The  rate  of  respira- 
tion accordingly  varies  as  does  that  of  the  pulse,  being 
more  rapid  in  woman  than  in  man,  in  a  child  than  in  an 
adult,  and  modified  by  position,  exertion,  excitement, 
and  other  conditions ;  but,  unlike  the  pulse,  it  is  partly 
under  control  of  the  will.  Eespirations  are  best  count- 


66  A  TEXT-BOOK  OF  NURSING 

ed,  when  possible,  without  the  knowledge  of  the  patient, 
as,  to  be  natural,  they  must  be  unconscious.  They  are 
somewhat  slower  during  sleep.  One  can  usually  see  the 
accompanying  rise  and  fall  of  the  chest;  but  to  count 
accurately,  the  hand  should  be  laid  flatly  and  lightly 
over  that  portion  of  the  abdomen,  just  below  the  breast- 
bone, known  as  the  epigastrium,  where  the  motion  may 
be  distinctly  felt.  Eespirations  below  eight,  or  above 
forty,  per  minute,  may  be  considered  as  indicative  of 
danger.  The  character,  as  well  as  the  frequency,  is 
subject  to  variations.  Breathing  in  man  is  abdominal, 
in  woman  chiefly  thoracic.  It  may  be  regular  or  irregu- 
lar, easy  or  labored,  quiet  or  noisy,  deep  or  shallow. 
Sometimes  it  presents  very  marked  peculiarities. 
When  each  breath  is  accompanied  by  a  deep  snoring 
sound,  it  is  said  to  be  stertorous.  Difficulty  of  breath- 
ing arising  from  any  source  is  called  dyspnoea;  total 
absence  of  breath  is  apncea.  Dyspnoea  arises  when, 
from  any  cause,  the  quantity  of  air  reaching  the  lungs 
is  disproportionate  to  the  amount  of  blood  sent  by  the 
heart  for  purification.  The  blood  may  be  in  an  un- 
healthy condition,  it  may  be  congested  in  the  pulmonary 
capillaries,  or  it  may  be  sent  too  quickly.  The  air  may 
be  unfit  to  perform  its  work,  or  it  may  be  shut  out  by 
disease  of  the  lungs  or  air-passages  or  by  the  presence 
of  a  foreign  body.  If  the  supply  of  pure  air  be  in  any 
way  entirely  cut  off,  asphyxia  results — that  is,  the  blood 
fails  to  be  oxygenated,  a  condition  necessarily  fatal  if 
not  soon  relieved. 

Carbonic-acid  gas  is  heavier  than  air,  so  much  so 
that  when  pure  it  can  be  poured  from  one  vessel  to 
another,  like  water.  The  air  nearest  the  ground  we 
might  then  expect  to  contain  the  largest  proportion  of 
this  gas.  It  does  not,  however,  so  accumulate,  owing  to 


RESPIRATION  67 

the  diffusive  power  of  gases,  stronger  even  than  the 
force  of  gravitation,  which  compels  such  as  are  in  con- 
tact thoroughly  to  intermingle.  The  winds  and  the 
rain  hasten  this  diffusion,  and  aid  in  the  purification  of 
the  air.  Still,  with  the  whole  animal  creation  constant- 
ly engaged  in  abstracting  oxygen  and  throwing  off  into 
the  air  a  poisonous  gas,  some  counteracting  influence 
is  necessary  to  prevent  the  entire  atmosphere  from  be- 
coming depleted,  and  unfit  to  sustain  life.  This  is 
found  in  the  vegetable  world,  which,  under  the  stimulus 
of  light,  reversing  the  plan  of  the  animal,  absorbs  car- 
bonic-acid gas,  and  gives  off  in  its  place  oxygen,  thus  se- 
curing the  continual  purification  of  the  air.  This  circle 
of  changes  is  perpetually  going  on,  each  of  the  great 
natural  kingdoms  deriving  its  own  proper  food  from 
the  atmosphere,  and  supplying  in  return  the  need  of  the 
other. 

When  we  are  out  of  doors  the  products  of  respira- 
tion are  continually  carried  away  by  atmospheric  cur- 
rents, while  the  lungs  are  as  constantly  supplied  with 
fresh  air.  But  in  any  confined  space  this  process  is  in- 
terrupted; the  air  is  rapidly  deprived  of  its  oxygen, 
while  noxious  and  irrespirable  substances  accumulate  in 
its  place,  unless  suitable  arrangement  is  made  for  the 
constant  renovation  of  the  atmosphere.  This  accounts 
for  the  now  familiar  fact  that  the  sick  and  wounded  so 
often  do  better  in  the  open  air  than  in  the  best  con- 
structed hospitals. 

Dr.  Barnes  says,  in  his  admirable  Notes  on  Surgical 
Nursing :  "  The  most  perfect  form  of  hospital,  in  a 
sanitary  view,  would  consist  of  a  fine,  dry  table-land 
or  very  gently  sloping  hillside,  while  the  ward  and 
its  fittings  might  consist  of  a  hammock,  a  large  um- 
brella, and  a  movable  screen."  He  had  in  mind  surgi- 


68  A  TEXT-BOOK  OP  NURSING 

cal  cases  particularly;  but  even  for  medical  treatment 
his  ideal  outfit  would  have  advantages,  so  true  is  it 
that  bad  .air  depresses  the  vital  powers,  predisposes 
to  disease,  and  aggravates  such  as  are  already  estab- 
lished. 

The  air  during  its  stay  in  the  pulmonary  cavity  ac- 
quires not  only  a  dangerous  proportion  of  carbonic-acid 
gas,  but  also  organic  impurities,  waste  matter  thrown 
off  from  the  blood  and  from  the  lung  substance.  Thus 
vitiated,  it  is  unfit  to  be  again  breathed. 

The  exhalations  from  the  lungs  are  but  one  of  the 
many  causes  conspiring  to  contaminate  the  atmosphere. 
All  the  other  excreta,  notably  that  of  the  skin,  lend 
their  aid,  and  there  are  frequent  sources  of  impurity 
external  to  the  body.  All  combustion  exhausts  oxygen 
and  liberates  injurious  gases.  A  single  ordinary  burner 
of  illuminating  gas  in  a  room  consumes  more  oxygen 
than  would  be  required  for  three  people.  Add  to  this 
the  inevitable  floating  dust  from  floors  and  walls,  from 
clothing,  bedding  and  furniture,  and  it  becomes  evi- 
dent that  with  such  impurities  arising  continually  and 
from  numberless  sources,  the  question  of  the  removal 
of  the  vitiated  air,  and  the  introduction  of  such  as  is 
in  a  fit  condition  for  use,  is  one  of  the  greatest  impor- 
tance, even  under  ordinary  circumstances. 

Where  there  is  sickness  it  becomes  a  still  more  vital 
consideration,  owing  to  the  presence  of  organic  matters 
in  increased  quantity,  and  of  most  deleterious  quality, 
and  to  the  reduced  resistive  powers  of  the  system.  A 
thousand  cubic  feet  of  air-space,  constantly  renewed, 
are  necessary  for  a  healthy  adult.  A  sick  person  should 
have  two  or  three  times  as  much,  since,  while  the  air  is 
more  quickly  contaminated,  renewal  must  be  less  rapid, 
owing  to  the  increased  susceptibility  to  draughts.  The 


VENTILATION  69 

above-named  is  the  minimum  supply  to  be  allowed. 
Too  much  fresh  air  it  is  impossible  to  get. 

The  substitution  of  pure  for  impure  air  constitutes 
ventilation.  There  is  happily  a  good  deal  of  accidental 
ventilation  through  the  impossibility  of  building  a 
house  perfectly  air-tight,  but  it  is  very  little  in  propor- 
tion to  the  need.  Exchange  of  air  spontaneously  affect- 
ed, as  by  doors  and  windows,  is  natural  ventilation.  It 
is  mainly  produced  by  inequalities  in  temperature, 
within  and  without,  which  set  the  air  in  motion.  Arti- 
ficial ventilation  may  be  either  by  extraction  or  pro- 
pulsion. A  chimney  with  an  open  fire  is  a  common  type 
of  the  extraction  method.  The  forcible  introduction  of 
fresh  air  by  fans  exemplifies  that  by  propulsion.  The 
former  is  at  once  the  simplest  and  most  effective. 
There  is  no  better  apparatus  for  ventilation  than  an 
open  fire.  The  draught  which  it  creates  carries  the  air 
from  the  room  up  the  chimney,  while  a  fresh  supply 
is  drawn  in  to  take  its  place.  It  is  most  important  to 
know  where  this  supply  comes  from.  If  there  is  no 
sufficient  inlet  from  out  of  doors  provided,  it  may  be 
sucked  in  from  some  adjoining  apartment  or  passage, 
itself  so  imperfectly  ventilated  as  to  afford  no  better 
air  than  that  the  place  of  which  it  takes.  A  strong 
draught  through  a  room  does  not  prove  it  well  venti- 
lated, unless  one  can  be  sure  that  the  inward  flow  is 
from  some  source  whence  there  is  no  danger  of  addi- 
tional contamination.  There  must  be  direct  connection 
with  the  outside  air,  and  the  higher  the  points  of  admis- 
sion, the  purer  is  it  likely  to  be. 

Two  constant  currents  are  necessary — one  outward 
removing  the  impure,  and  one  inward  supplying  pure 
air.  Inlets  and  outlets  should  be  of  equal  capacity,  on 
opposite  sides  of  the  room,  and  at  different  heights,  to 


70  A  TEXT-BOOK  OP  NURSING 

secure  thorough  distribution.  It  is  best  to  have  them 
small  and  numerous,  giving  rise  to  many  and  moderate 
currents.  They  should  be  as  far  as  possible  from  the 
patient,  and  from  each  other.  It  is,  of  course,  much 
more  difficult  to  thoroughly  ventilate  a  small  room  than 
a  large  one,  and  the  liability  to  injurious  draughts  is 
greater. 

It  is  impossible  to  keep  the  air  of  a  sick-room  abso- 
lutely as  pure  as  that  outside.  That  is,  however,  the 
ideal  condition,  and  the  one  to  which  the  nurse  should 
aspire.  In  a  large  hospital  the  mutually-involved  sub- 
jects of  ventilation  and  warmth  come  but  little  under 
the  control  of  the  nurse.  You  will  have  only  to  ob- 
serve and  report  any  departure  in  your  ward  from  the 
proper  standard.  In  private  nursing  the  matter  comes 
more  fully  under  your  own  management,  and  to  keep 
pure  the  air  of  the  sick-room  is  a  most  important  part 
of  your  duty.  It  is  one  in  the  accomplishment  of  which 
you  are  likely  to  find  many  difficulties.  You  will  have 
to  contend  with  a  popular  prejudice  against  fresh  air, 
unfortunately  not  altogether  confined  to  the  uneducated 
classes,  and  also  with  the  real  danger  of  chilling  the 
patient.  There  are  some  cases  in  which  open  windows 
in  the  sick-room  itself  are  inadvisable  in  very  cold  or 
damp  weather.  There  is  still  the  necessity  for  keeping 
the  air  fresh  and  wholesome,  and  it  requires  even  more 
than  usual  care  and  watchfulness  to  do  this.  The  air 
must  be  admitted  from  outside  into  some  adjoining 
room,  and  then  be  warmed  before  it  is  allowed  to  reach 
the  patient.  In  all  ordinary  cases,  however,  the  win- 
dows may  be  kept  open,  more  or  less,  day  and  night, 
without  danger.  Ventilation  during  the  night  is  not 
less  important  than  during  the  day,  though  the  air  must 
be  more  cautiously  admitted,  having  missed  the  warm- 


VENTILATION  71 

ing  and  purifying  influence  of  the  sunshine.  It  is  still 
infinitely  to  be  preferred  to  the  poisoned  atmosphere  of 
a  close,  inhabited  room,  and  must  not  be  altogether 
shut  out.  Cold  is  greatest,  and  the  body  least  able  to 
resist  it,  in  the  early  morning,  just  before  daylight ;  but 
it  is  more  heat,  not  less  air,  that  is  called  for.  Instead 
of  closing  the  windows,  and  adding  the  benumbing  ef- 
fect of  carbonic-acid  poisoning  to  that  of  cold,  stir  up 
the  fire,  and  give  your  patient  additional  clothing  and 
foot-warmers.  If  there  must  be  a  choice  of  the  two 
evils,  air  too  cold  will  in  most  cases  do  less  harm  than 
foul  air.  In  warm  weather,  when  open  windows  and 
doors  are  matters  of  course,  there  is  but  little  difficulty 
in  obtaining  an  abundant  supply  of  fresh  air.  But  it  is 
a  too  little  appreciated  fact  that  the  necessity  is  none 
the  less  in  the  coldest  weather.  It  is  a  common  error 
to  confound  cold  air  with  clean  air,  and  to  suppose 
that  ventilation  can  be  measured  by  a  thermometer. 
Changes  in  the  quality  of  the  air  are  not  so  sensibly 
felt  as  changes  in  its  temperature;  the  more  care  is 
needed  to  guard  against  them.  No  thermometer  regis- 
ters its  deterioration;  the  only  test  ordinarily  practi- 
cable is  by  the  sense  of  smell.  A  "  sick-room  odor,"' 
perceptible  upon  entering  from  the  fresh  air,  is  incon- 
trovertible evidence  of  poor  ventilation.  It  is  obviously 
desirable  that  a  nurse  should  have  a  good  nose;  but 
after  a  short  time  spent  in  a  vitiated  atmosphere,  its 
sensitiveness  will  be  lost,  and  not  at  once  regained  even 
out  of  doors,  so  that  it  ceases  to  be  a  reliable  guide. 
One  can  not  be  too  watchful,  for  there  are  few  more 
mortifying  occurrences  for  a  nurse  than  to  have  the 
doctor  come  in  from  outside,  and  remark,  "  Your  room 
is  close." 

Even  in  the  coldest  weather,  windows  may  be  fre- 


72  A  TEXT-BOOK  OF  NUESING 

quently  thrown  wide  open  for  a  few  moments  at  a  time, 
the  patient  being  meanwhile  protected  by  additional 
covering.  A  large  umbrella  opened,  with  a  shawl  or 
blanket  thrown  over  both  it  and  the  patient,  affords  an 
effectual  screen.  If  the  patient  is  able  to  move  about, 
advantage  should  be  taken  of  every  occasion  when  he 
leaves  the  room,  to  ventilate  more  thoroughly  than  can 
be  done  in  his  presence.  But  do  not  depend  entirely 
upon  such  occasional  opportunities.  The  contamina- 
tion of  the  air  is  continuous ;  its  purification  should  be 
equally  so.  There  are  numerous  simple  devices  for 
opening  windows  and  at  the  same  time  protecting  the 
patient  from  direct  draughts.  The  lower  sash  may  be 
raised,  or  the  upper  one  lowered,  and  the  entire  open- 
ing closed  by  a  board.  The  current  of  air  then  enters 
only  in  the  middle,  between  the  two  sashes,  and  is 
given  an  upward  direction.  Or,  placing  the  board  on 
the  window-sill,  a  little  inside  of  and  extending  some- 
what higher  than  the  opening,  similarly  directs  the  cur- 
rent, and  gives  two  apertures  for  the  admission  of  air. 
Currents  of  cold  air  should  be  always  first  directed 
upward. 

As  has  been  suggested,  the  best  method  of  securing 
an  outward  flow  of  the  foul  air  is  by  an  open  fire.  In  a 
large  room  it  may  be  insufficient  for  heating ;  but  other 
appliances  ought  to  be  supplementary  to,  not  substitutes 
for  this.  If  it  is  too  warm  for  a  fire  to  be  desirable,  a 
lamp  burning  on  the  hearth  is  good  to  create  a  draught. 
Extraction  flues  must  in  some  way  be  heated,  or  they 
will  not  draw.  To  allow  open  windows,  there  must  be 
a  surplus  of  heat.  Economical  housekeepers  will  some- 
times object  to  "heating  all  outdoors,"  but  it  is  an 
economy  in  the  wrong  direction.  Stoves  assist  ventila- 
tion in  the  same  way  as  grate-fires,  though  not  to  the 


WARMTH  73 

same  extent,  by  drawing  off  the  foul  air.  A  pan  of 
water  should  be  kept  on  the  stove,  to  dampen  the  air  by 
its  evaporation.  Heat  without  moisture  is  injurious,  a 
certain  amount  of  watery  vapor  being  essential  to  the 
wholesomeness  of  the  air.  Gas  or  oil  heaters  are  espe- 
cially objectionable,  as  they  have  no  provision  for  the 
removal  of  the  products  of  combustion. 

Patients  with  pulmonary  disease  often  find,  to  their 
surprise,  that  they  breathe  with  less  difficulty  in  damp 
and  foggy  weather  than  on  a  clear,  dry  day.  Such 
may  derive  considerable  relief  from  a  kettle  of  water 
kept  boiling  vigorously  in  the  room.  A  large  sponge, 
or  towel,  hung  in  front  of  a  hot-air  register,  and  kept 
wet,  will  also  sensibly  dampen  the  atmosphere.  In  all 
disorders  of  the  respiratory  system,  if  no  special  direc- 
tions are  given  by  the  physician,  keep  the  room  at  a 
temperature  of  from  70°  to  75°  Fahr. ;  in  purely  febrile 
disease,  65°  is  more  suitable;  for  other  cases,  68°  is  a 
good  point.  Whatever  temperature  is  decided  to  be  best 
should  be  steadily  maintained. 

It  is  to  be  remembered  that  there  is  especial  neces- 
sity for  warmth  in  children,  in  the  very  aged,  and  in 
cases  of  diarrhoea.  It  is  of  far  greater  importance  to 
keep  the  sick-room  warm  when  the  patient  is  out  of  bed 
than  when  he  is  in  it.  People  rarely  take  cold  under 
the  bedclothes.  Convince  your  patient  of  this,  if  pos- 
sible, and,  observing  all  precautions  against  the  possi- 
bility, do  not  allow  any  prejudice,  either  on  his  part  or 
that  of  his  anxious  but  ill-instructed  friends,  to  prevent 
you  from  giving  him  an  ample  supply  of  fresh,  pure 
air.  Remember  that  the  lungs  can  not,  in  any  confined 
space,  fulfill  their  office  of  purifying  the  blood  and  re- 
moving its  waste  particles  unless  provision  is  made  for 
the  constant  renovation  of  the  air.  This  can  hardly  be 


74  A  TEXT-BOOK  OF  NURSING 

too  much  emphasized.  There  are  three  important  rules 
in  regard  to  ventilation,  viz. :  sufficient  pure  air  must  be 
introduced;  the  foul  air  must  be  removed;  these  ends 
must  be  achieved  without  injurious  draughts. 

"  But  if  the  pilot  slumber  at  the  helm, 
The  very  wind  that  wafts  us  toward  the  port 
May  dash  us  on  the  shelves.     The  steersman's  part 
Is  vigilance,  blow  it  rough  or  smooth." 

Scott. 


CHAPTER   VI 

"Cleanliness  of  body  was  ever  deemed  to  proceed  from  a  due 
reverence  to  God." — Francis  Bacon. 

THE  skin  is  not  only  a  protective  covering  for  the 
body,  but  a  complex  excretory  organ,  doing  as  impor- 
tant a  work  in  the  elimination  of  waste  products  as  the 
lungs,  kidneys,  and  gastro-intestinal  tract.  It  consists 
of  two  distinct  layers,  the  derma,  cutic  vera,  or  true 
skin,  underneath;  and  the  epidermis,  cuticle,  or  scarf- 
skin,  on  the  outside.  The  true  skin  is  filled  with  blood- 
vessels and  nerves;  the  cuticle  contains  none  of  these, 
but  is  connected  with  them  by  numbers  of  sudoriferous 
tubes.  The  surface  of  the  body  is  closely  covered  with 
the  openings  of  these  tubes,  known  as  pores.  From 
these  pores,  water  and  excrementitious  matters  are  con- 
stantly being  thrown  off  in  the  form  of  vapor.  By  this 
steady  evaporation  the  temperature  of  the  body  is  regu- 
lated. If  the  body  be  covered  with  an  impermeable 
coating,  so  as  to  entirely  obstruct  this  process,  death 
shortly  ensues.  The  scarf-skin  is  continually  scaling 
off  and  being  renewed  from  beneath;  at  the  same  time; 
solid  matters  are  to  some  extent  deposited,  as  the  water 
evaporates  from  the  sweat-ducts.  Besides  these,  there 
is  another  set  of  glands  in  the  skin,  called  the  seba- 
ceous glands,  secreting  a  kind  of  oily  matter,  which 
serves  to  keep  the  skin  soft  and  supple.  The  excess  of 
this  sebaceous  matter,  the  cast-off  scales  of  the  cuticle, 

75 


76  A  TEXT-BOOK  OF  NURSING 

and  the  solid  deposit  from  the  perspiration,  remain  on 
the  surface,  and,  unless  removed,  fill  the  pores  and  pre- 
vent further  evaporation.  Thus,  even  in  a  state  of 
health,  frequent  and  thorough  ablution  is  a  matter  of 
the  first  hygienic  import.  Dirt  of  any  kind  blocks  the 
mouths  of  the  sweat-bearing  tubes  and  impedes  their 
action.  This  throws  more  work  upon  the  other  excre- 
tory organs,  disturbing  the  balance  of  their  functions, 
so  that  disease  may  often  be  traced  simply  to  a  failure 
to  keep  the  pores  of  the  skin  open. 

In  sickness  it  is  even  more  serious,  for  the  exhala- 
tions of  disease  are  morbid  and  dangerous,  yet  bathing 
is  often  neglected  through  fear  that  the  patient  will 
take  cold.  But  cleanliness  is  a  positive  aid  to  recovery, 
and,  with  proper  precautions,  there  are  very  few  pa- 
tients who  can  not  be  washed  without  danger.  In  al- 
most all  cases  at  least  a  sponge  bath  in  bed  can  be  given, 
care  being  taken  neither  to  chill  nor  fatigue  the  patient. 
The  bed  should  be  protected  by  an  extra  rubber  and 
draw-sheet.  The  room  should  be  warm  and  free  from 
draughts,  and  everything  likely  to  be  needed  at  hand — 
plenty  of  hot  and  cold  water,  soap,  sponges,  towels, 
clean  clothing,  etc.  Take  plenty  of  time,  and,  exposing 
only  a  small  part  of  the  body  at  a  time,  wash,  dry,  and 
cover  it  before  proceeding  further.  Use  a  sponge  or  a 
flannel  wash-cloth.  This  will  retain  the  heat  much  bet- 
ter than  cotton.  After  the  bath  some  light  refreshment 
may  be  allowed,  if  the  patient  seems  at  all  fatigued.  A 
bath  should  never  be  given  within  two  hours  after  a 
full  meal. 

The  clothing  should  always  be  warmed  before  it  is 
put  on.  To  change  a  night-dress,  or  shirt,  slip  off  the 
sleeves  of  the  soiled  one  and  pull  it  up  toward  the  neck. 
Then  put  the  arms  in  the  clean  sleeves,  lift  the  patient's 


BATHS  77 

head  and  shoulders,  and  the  soiled  garment  can  be 
slipped  off  over  the  head  with  the  same  motion  that  puts 
on  the  clean  one.  Pull  the  latter  down  smoothly  under 
the  back,  but  not  too  tight.  In  this  way  the  patient 
has  only  to  be  raised  once.  If  he  ought  not  to  be  lifted 
at  all,  the  shirt  or  gown  must  be  ripped  all  the  way  down 
the  front.  In  taking  it  off,  slip  out  one  arm  and  put  on 
the  corresponding  clean  sleeve,  work  it  under  the  shoul- 
ders, pushing  the  soiled  one  before  it,  and  change  the 
other  sleeve.  If  two  garments  are  worn,  fit  one  inside 
the  other  before  beginning,  and  put  them  on  as  one. 
Where  there  is  an  injured  arm  or  side,  begin  with  it  in 
putting  on  a  garment,  but,  in  taking  one  off,  begin 
always  with  the  sound  side. 

The  mouth  should  be  often  washed,  and  the  teeth 
brushed,  or  wiped  off  with  a  bit  of  soft  cloth.  Water 
containing  a  few  drops  of  tincture  of  myrrh,  Candy's 
fluid,  or  listerine,  is  good  to  rinse  out  the  mouth.  To 
remove  sordes  from  the  teeth,  a  mixture  of  lemon-juice, 
glycerin  and  ice-water,  in  equal  parts,  will  be  found  effi- 
cacious. Another  good  mouth  wash  is  made  by  adding 
one  minim  of  crude  carbolic  acid  to  two  ounces  each  of 
alcohol  and  water. 

In  combing  the  hair  begin  at  the  ends,  holding  the 
hair  firmly  near  the  roots,  to  avoid  pulling  and  to  keep 
the  head  steady.  It  is  best  arranged  in  two  braids,  or 
twisted  on  top  of  the  head,  so  that  the  patient  will  not 
have  to  lie  on  a  knot.  When  the  hair  is  much  matted,  it 
is  better  to  cut  it  short,  though,  with  time  and  patience, 
very  bad  tangles  can  be  straightened  out.  If  the  pa- 
tient is  in  the  hands  of  a  good  nurse  from  the  commence- 
ment, it  will  never  be  allowed  to  get  into  such  a  condi- 
tion. To  clean  the  hair  there  is  nothing  better  than 
tar  soap.  A  little  aromatic  spirit  of  ammonia  in  water  is 


78  A  TEXT-BOOK  OP  NURSING 

good,  and  it  contains  alcohol  enough  to  make  it  dry 
quickly.  If  the  hair  is  naturally  dry,  vaseline  well 
rubbed  in  is  a  better  dressing.  Blood-clots  in  the  hair, 
as  after  a  scalp-wound,  can  be  dissolved  out  by  a  solu- 
tion of  washing  soda.  In  disinfecting  after  exposure  to 
contagious  diseases  use  a  saturated  solution  of  boracic 
acid.  As  a  rule,  the  hair  should  be  brushed,  the  teeth 
cleaned,  and  the  hands  and  face  washed  at  least  twice 
daily,  and  the  whole  body  twice  every  week.  The  nails 
should  not  be  neglected. 

Baths  are  used  for  remedial  purposes  as  well  as  sim- 
ply for  cleanliness.  They  may  be  general  or  local,  sim- 
ple or  medicated,  cold,  tepid,  or  hot;  in  the  form  of 
liquid,  vapor,  or  air.  Judiciously  employed,  baths  are 
valuable  therapeutic  agents,  but  their  unadvised  use,  as 
is  true  of  all  powerful  remedies,  may  be  hurtful  rather 
than  helpful.  The  exact  temperature  and  duration  of 
any  bath  ordered  must  be  obtained  from  the  doctor, 
and  the  effect  upon  the  patient  carefully  noted.  Tan- 
ner gives  the  following  temperatures  as  to  be  understood 
when  the  definite  degree  of  heat  is  not  specified: 

Cold  33°-  65°  Fahr. 

Cool  65°-  75° 

Temperate 75°-  85° 

Tepid   85°-  92° 

Warm    ' 92°-  98° 

Hot 98°-112° 

To  put  a  feeble  patient  in  a  bath,  wrap  him  in  a 
sheet  and  lower  it  gently  into  the  water.  Have  a  warm, 
dry  sheet  ready  to  roll  him  in  when  he  leaves  the  bath. 
Over  this  fold  a  blanket,  and,  putting  him  in  a  well- 
protected  bed,  leave  him  wrapped  in  them  for  a  few 
minutes.  In  this  way  he  will  be  made  dry  without  extra 


BATHS  7d 

fatigue.  A  few  long  strokes  with  a  soft  towel  will  be 
all  that  is  needed  to  complete  the  process  when  the 
wrappings  ape  removed.  If  the  bath  is  to  be  very  soon 
repeated,  it  is  better  not  to  put  on  the  clothes,  but  to 
leave  the  patient  folded  in  a  dry  sheet,  ready  for  the 
next  plunge. 

Cold  baths  are  employed  either  to  produce  reaction, 
refrigeration,  or  nervous  shock.  Cold  water  abstracts 
the  heat  of  the  body,  and  affects  the  internal  organs 
through  the  nervous  system.  Upon  first  entering  a 
cold  bath  there  is  experienced  a  sense  of  chilliness  and 
depression.  The  pulse  is  quickened,  but  the  tempera- 
ture of  the  surface  is  lowered,  and  the  blood  accumulates 
in  the  internal  organs.  A  condition  of  reaction  soon 
follows,  with  invigorated  circulation,  a  feeling  of 
warmth  and  exhilaration;  but  if  the  immersion  be  too 
long  continued  the  coldness  returns,  with  weakness  of 
the  pulse  and  general  depression.  The  cold  bath  is 
sometimes  used  as  a  tonic  in  cases  of  debility,  but  there 
must  be  a  certain  amount  of  vigor  to  render  it  endura- 
ble. It  is  best  taken  in  the  morning,  and  followed  by 
vigorous  rubbing  and  gentle  exercise.  The  head  must 
be  first  submerged,  and  the  bath  continued  only  long 
enough  for  the  reactionary  stage  to  be  reached — not 
more  than  five  minutes.  The  colder  the  water,  the 
sooner  reaction  takes  place.  A  cold  sponge-bath  can 
be  taken  with  much  less  danger  of  chill  if  one  stand 
with  the  feet  in  warm  water.  The  cold  bath  is  a  most 
speedy  and  effective  way  of  bringing  down  a  high  tem- 
perature. It  may  be  lowered  from  one  to  six  degrees. 
The  shock  of  sudden  immersion  in  cold  water  may  be 
avoided  by  beginning  with  a  tepid  bath,  and  gradually 
reducing  it  as  much  as  desired  by  adding  cold  water  or 
ice.  The  temperature  must  be  taken  by  rectum  and 


80  A  TEXT-BOOK  OF  NURSING 

the  patient  removed  from  the  bath  before  it  is  lowered 
to  the  required  point,  for  it  will  continue  to  fall  for  some 
little  time  afterward,  until  the  heat  of  the  interior  and 
exterior  of  the  body  becomes  equalized. 

The  "  Brand  "  method  is  much  used  for  the  reduc- 
tion of  temperature  in  cases  of  typhoid  fever.  In  prep- 
aration for  this,  the  patient  should  first  empty  the  blad- 
der, and  if  perspiring,  should  be  thoroughly  dried. 
Cover  him  then  with  a  sheet,  and  lift  gently  into  a  tub 
of  water  at  a  temperature  of  70°  F.  During  the  im- 
mersion, rub  him  vigorously,  and  if  he  be  not  too  weak, 
encourage  him  to  rub  himself.  There  should  be  a  sup- 
port for  the  head.  This  can  be  made  of  a  strip  of  gauze 
or  muslin  fastened  securely  across  one  end  of  the  tub. 
On  the  head  should  be  kept  a  compress  wrung  out  of 
ice-water,  or  ice-water  may  be  poured  on  the  head  three 
or  four  times  during  the  bath.  This  is  very  important 
when  the  nervous  symptoms  are  marked.  After  fifteen 
minutes,  the  patient  should  be  lifted  upon  the  bed  pre- 
viously prepared  with  a  rubber  sheet  and  blanket.  The 
wet  sheet  should  be  removed,  and  be  replaced  by  a  warm 
blanket,  under  which  the  patient  is  briskly  rubbed  dry. 
This  done,  take  away  the  rubber  and  blankets,  and  cover 
him  comfortably.  As  soon  as  shivering  ceases,  gener- 
ally in  about  twenty  minutes  after  removal  from  the 
bath,  the  temperature  should  be  taken  to  ascertain  the 
result.  If  put  off  longer  than  this,  the  invalid  may  be 
asleep,  and  should  not  be  disturbed. 

The  shivering  which  comes  on  ordinarily  in  five  or 
ten  minutes  after  putting  the  patient  in  the  water, 
should  not  interfere  with  the  continuation  of  the  bath, 
but  if  an  almost  absolute  lack  of  pulse  with  skin  cya- 
nosed  should  develop,  he  should  be  at  once  removed  to 
the  bed,  hot  water  bottles  be  applied  to  the  legs  and 


BATHS  81 

feet,  and  stimulants  be  given,  if  the  condition  persists. 
In  cases  of  typhoid  fever,  these  baths  will  be  ordered 
repeated  at  intervals  of  not  less  than  three  hours.  If 
at  the  end  of  three  hours  after  the  bath,  the  tempera- 
ture is  between  101°  and  102°  F.,  it  is  to  be  taken  again 
in  an  hour;  if  between  100°  and  101°,  in  two  hours;  if 
below  100°,  not  for  three  hours.  Generally,  when  the 
temperature  reaches  102°,  the  bath  will  be  given,  if 
three  hours  have  elapsed  since  the  previous  one. 

Instead  of  a  bath-tub,  a  fever  cot  is  sometimes  used. 
This  is  a  frame  covered  with  sacking,  below  which  a 
rubber  cloth  is  hung,  one  end  lower  than  the  other.  The 
patient,  wrapped  in  a  sheet,  lies  on  the  sacking,  and  has 
buckets  of  cold  water  poured  over  him  at  stated  inter- 
vals. The  water  runs  through  into  the  rubber  trough, 
which  conducts  it  into  a  pail  at  the  foot  of  the  cot. 

The  wet  pack  or  envelope  bath  is  another  method 
of  applying  cold  or  heat.  To  prepare  for  this,  first  put 
three  or  four  blankets  on  the  bed,  and  over  these  a  sheet 
wrung  out  in  cold  or  hot  water,  as  ordered.  Lay  the 
patient  on  this,  and  fold  the  sheet  over  him,  tucking  it 
in  well  on  both  sides  from  the  neck  to  the  ankles,  the 
feet  not  included.  The  blankets  are  then  to  be  folded 
over  him,  one  by  one,  in  the  same  way,  and  the  patient 
left  in  them  from  thirty  minutes  to  three  hours.  Give 
plenty  to  drink,  and  keep  the  feet  warm.  This  treat- 
ment is  usually  very  comfortable  to  the  patient,  and  he 
will  often  fall  asleep  while  in  the  pack.  It  will  render 
the  skin  moist,  subdue  restlessness  and  delirium,  and 
reduce  fever.  Upon  removal,  dry  off  the  patient  quick- 
ly and  wrap  in  a  warm  dry  blanket  for  some  hours.  If 
the  object  is  simply  to  reduce  temperature,  the  sheet 
wrung  out  in  cold  water  may  be  employed,  without  the 
superimposed  blankets.  It  should  be  changed  every  ten 


82  A  TEXT-BOOK  OP  NURSING 

minutes.  The  same  effect  may  be  more  easily  produced 
by  applying  towels  wrung  out  in  ice-water,  dry  enough 
not  to  drip,  one  after  another,  from  the  neck  downward. 
When  the  feet  are  reached,  begin  again  at  the  head,  and 
renew  each  in  succession,  continuing  as  long  as  neces- 
sary. 

Cold  or  tepid  sponging  often  gives  much  relief  to 
a  feverish  condition.  Sponge  always  downward,  and 
wrap  the  patient,  still  wet,  in  a  warm  blanket,  leaving 
him  undisturbed  for  an  hour.  Alcohol  in  the  water 
mates  it  more  cooling  by  its  rapid  evaporation.  Alcohol 
alone  may  be  used. 

If  it  is  desired  to  produce  a  shock  upon  the  nervous 
system,  as  sometimes  when  there  is  disease  of  the  brain 
or  nerves,  affusion  is  employed.  This  is  simply  throw- 
ing cold  water  upon  the  body.  The  shower  bath  is  one 
form  of  it,  and  the  douche  another.  The  latter  is  most 
used  as  a  local  tonic.  The  stream  should  be  directed 
from  a  height  not  exceeding  ten  feet,  and,  if  the  affected 
part  is  very  weak  or  sensitive,  should  first  be  brought 
to  bear  upon  the  surrounding  portions,  and  only  by 
degrees  immediately  upon  it.  A  douche  of  hot  and  cold 
water  alternately  is  often  advised. 

A  general  warm  bath  is  used  to  induce  perspiration, 
soothe  pain,  or  relax  spasm.  The  effect  of  warm  or  hot 
water  is  at  first  agreeable.  Transpiration  is  increased 
through  both  lungs  and  skin,  and  the  circulation  accel- 
erated. A  very  hot  bath  excites  and  stimulates  the  nerv- 
ous system,  while  tepid  or  warm  water  rather  calms  and 
soothes  it.  If  the  water  is  too  hot,  or  the  bath  too  long 
continued,  languor,  giddiness,  or  faintness  may  super- 
vene. The  temperature  should  be  tested  with  a  ther- 
mometer, and  the  same  degree  of  heat  kept  up  through- 
out. Care  must  be  taken  that  no  part  of  the  body  comes 


BATHS  83 

directly  under  the  hot-water  tap.  Keep  the  head  out, 
and  cool.  An  invalid  should  never  be  left  alone  in  the 
water,  and  must  be  taken  out  of  it  at  once  if  any  sign  of 
faintness  appears.  A  hot  bath  will  not  be  given  during 
the  menstrual  period,  or  in  the  last  stages  of  pregnancy. 
Some  surgical  cases  have  been  successfully  treated  by 
long-continued  immerison  of  the  injured  part  in  hot 
water.  For  this  purpose,  especially  constructed  tubs  are 
provided.  Water  as  hot  as  can  be  borne  is  the  best  ap- 
plication for  all  sprains  or  bruises. 

A  foot-bath  is  usually  given  to  relieve  the  head,  and 
should  be  as  hot  as  possible.  If  the  patient  is  able  to 
sit  in  a  chair,  see  that  he  is  warmly  wrapped  up,  and 
cover  both  patient  and  tub  with  a  blanket.  Let  the 
water  come  nearly  to  the  knees.  Adding  mustard  will 
increase  the  effect.  The  bath  can  be  given  in  bed,  if 
necessary,  though  less  conveniently.  Have  it  well  pro- 
tected, turn  up  the  clothes  from  the  foot  of  the  bed,  di- 
rect the  patient  to  lie  on  the  back  and  bend  the  knees, 
when  the  feet  can  be  set  in  a  foot-tub  or  a  deep  bowl  of 
water.  Have  it  well  balanced,  cover  with  a  blanket,  and 
let  the  feet  soak  from  a  quarter  to  half  an  hour.  Then 
dry  them  well,  and  either  wrap  in  flannel  or  put  on 
woolen  stockings.  The  same  treatment  will  be  found 
useful  for  cold  feet. 

For  a  sitz  or  hip  bath,  the  patient  is  immersed  from 
the  knees  to  the  waist  and  covered  with  blankets.  The 
temperature  of  the  water  must  be  well  kept  up,  and  the 
bath  prolonged  about  twenty  minutes.  The  object  be- 
ing to  excite  the  menstrual  flow,  the  bath  should  be 
given,  as  nearly  as  can  be  calculated,  at  the  time  when 
that  would  naturally  appear.  The  hot  foot-bath  is  some- 
times employed  for  the  same  purpose.  Neither  should 
be  given  when  there  is  any  suspicion  of  pregnancy. 


84  A  TEXT-BOOK  OF  NURSING 

For  a  hot-air  bath,  an  alcohol  lamp  and  a  body- 
cradle  are  required.  The  sheets  and  the  patient's  cloth- 
ing are  taken  off,  blankets  enough  put  over  the  cradle 
to  render  it  nearly  air-tight,  and  snugly  tucked  in.  The 
heated  air  should  enter  on  a  level  above  the  patient, 
whose  body  should  be  sponged  with  tepid  water  until 
there  is  free  perspiration.  The  lamp  may  be  kept  burn- 
ing for  twenty  minutes  or  half  an  hour,  and  the  patient 
then  sponged  off  with  cool  water.  A  vapor  bath  may 
be  given  with  a  similar  apparatus,  or  by  conducting 
steam  under  the  cradle  from  the  spout  of  a  boiling  tea- 
kettle. Still  another  way  is  by  wrapping  hot  bricks  in 
wet  flannel,  and  setting  them  on  earthen  dishes  under 
the  cradle. 

Both  the  hot-air  and  vapor  baths  may  in  less  severe 
cases  be  given  in  a  cane-bottomed  chair,  constituting  a 
modified  Turkish  bath.  Let  the  patient,  entirely  with- 
out clothing,  sit  on  a  wicker  chair,  with  the  feet  on  a 
stool.  Cover  with  several  blankets,  and  under  the  chair 
burn  a  spirit-lamp  with  a  large  wick.  Let  the  patient 
drink  freely,  and,  after  he  has  perspired  sufficiently,  put 
him  in  a  general  bath  of  75°  or  80°,  or  pour  over  him 
a  pail  of  cold  water.  Dry  thoroughly,  and  keep  him 
warm  afterward. 

Both  liquid  and  vapor  baths  may  be  medicated.  A 
mercurial  vapor-bath  is  given  like  the  above,  but  with  a 
special  apparatus  for  the  evaporation  of  calomel.  This, 
after  being  deposited  upon  the  skin,  is  not  to  be  rubbed 
off.  An  acid  vapor  may  be  produced  by  evaporating 
vinegar. 

For  an  alkaline  bath,  add  half  a  pound  of  carbonate 
of  soda  to  fifteen  gallons  of  hot  water. 

A  sulphur  bath  is  prepared  by  adding  to  each  gallon 
of  water  twenty  grains  of  sulphuret  of  potassium.  This 


MASSAGE  85 

must  be  given  in  a  wooden  or  porcelain-lined  vessel,  as 
the  sulphides  discolor  most  metals.  This  is  ordered 
sometimes  for  rheumatic  affections,  and  sometimes  for 
disease  of  the  skin — in  the  latter  case  not  usually  until 
the  subsidence  of  the  acute  stage,  as  it  tends  rather  to 
aggravate  the  rash.  With  all  skin  diseases,  rain  water 
should  be  used,  or  hard  water  softened  by  the  addition 
of  soda,  bran,  starch,  or  gelatin.  The  skin  should  not 
be  rubbed,  but  dabbed  dry  with  soft  towels. 

For  a  bran  bath,  boil  a  pound  of  bran  in  a  bag  for  a 
quarter  of  an  hour,  drain  off  the  fluid,  and  add  it  to  the 
bath. 

For  a  starch  bath,  take  half  a  pound  of  starch,  and 
mix  it  with  two  quarts  of  water  before  adding  it  to  the 
bath. 

A  salt  bath  is  usually  given  cold  for  tonic  effect. 
Either  sea-water  may  be  used,  or  a  solution  of  rock-salt 
in  the  proportion  of  one  pound  to  four  gallons  of  water. 

After  any  emollient  or  soothing  bath,  the  patient 
should  be  kept  quiet;  after  a  stimulating  bath,  ener- 
getic friction  and  exercise  are  in  order. 

MASSAGE 

Massage  is,  in  the  hands  of  a  skilled  operator,  a 
valuable  mode  of  treatment,  and  is  now  much  used. 
It  will,  to  a  considerable  extent,  take  the  place  of  ac- 
tive exercise,  keeping  the  muscles  strong  and  supple.  It 
develops  heat  at  the  points  of  contact,  so  elevating  the 
general  temperature  and  dilating  the  vascular  system. 
It  furthers  absorption,  accelerating  the  motion  of  the 
blood  currents,  removing  effete  matters,  and  so  promo- 
ting nutrition.  It  has  usually  a  powerfully  sedative 
effect  upon  the  nerves,  though  in  some  instances  it  will 

be  found  to  excite  rather  than  to  soothe.    Insomnia  and 

7 


86  A  TEXT-BOOK  OP  NURSING 

neuralgia  can  often  be  relieved  by  it,  and  spinal  irrita- 
tion to  some  extent  controlled.  In  the  treatment  of 
nervous  disorders  it  is  often  combined  with  rest,  rigid 
dietetics,  and  electrical  excitation.  Perhaps  the  most 
conspicuously  good  results  are  in  cases  of  chronic  joint 
affections  and  thickening  from  inflammatory  deposits. 

Massage  consists  of  a  peculiar  kneading  of  the  un- 
derlying muscles,  and  is  quite  distinct  from  friction  and 
percussion,  which  touch  only  the  external  tissues,  but  it 
is  often  combined  with  them,  and  with  the  "  Swedish 
movements,"  active,  passive,  resistive,  or  assistive.  The 
word,  as  commonly  used,  may  be  understood  to  embrace 
all  forms  of  manipulation. 

A  few  desultory  lessons  will  not  qualify  you  to  give 
or  teach  massage.  It  takes  time,  patience,  and  a  great 
deal  of  strength  to  acquire  the  art,  and  constant  practice 
to  retain  any  facility  in  it;  for,  even  when  once  gained, 
it  is  soon  lost  by  disuse.  Mere  rubbing  may  be  agree- 
able and  useful,  but  it  is  not  massage. 

Theoretical  instruction  does  not  amount  to  much  on 
such  a  subject,  and  there  are  many  variations  in  vogue 
even  among  good  masseurs,  so  that  the  most  that  can 
be  attempted  here  is  to  give  a  few  of  the  points  in 
which  the  most  rational  operators  agree,  and  which 
experience  has  shown  to  be  valuable.  It  is  very  hard 
work  always — too  hard  to  combine  with  nursing — but  a 
skilled  manipulator  will  accomplish  more  in  less  time, 
and  with  less  effort,  than  an  inexperienced  one.  The 
whole  body  can  be  gone  over  pretty  thoroughly  in  an 
hour,  after  which  a  general  rise  of  temperature  of  about 
one  degree  may  be  looked  for. 

The  hands  need  to  be  at  once  strong  and  soft,  the 
motions  smooth  and  even,  never  jerky.  The  work 
should  be  done  from  the  wrists,  not  from  the  shoulders, 


MASSAGE  87 

and  you  want  equal  flexibility  and  freedom  of  action  in 
both  hands.  All  movements  should  be  begun  slowly 
and  gently,  and  their  force  and  frequence  gradually  in- 
creased. A  very  tender  spot  can  be  barely  touched  at 
first,  but  after  a  little  skillful  handling  an  amount  of 
force  can  be  employed  which  would  have  seemed  in- 
credible. The  whole  hand,  not  merely  the  ends  of  the 
fingers  should  be  used.  In  malaxation  or  massage  prop- 
er— manipulation  of  the  deeper  tissues — the  work  is 
chiefly  performed  by  the  ball  of  the  thumb  and  the 
palm  of  the  hand.  Each  muscle  is  kneaded  and  rolled 
with  carefully  graded  force.  Begin  at  the  extremities 
and  work  toward  the  trunk.  If  the  feet  are  cold,  keep 
at  them  until  they  are  quite  warm  before  going  on. 
Take  up  each  group  of  muscles  systematically,  com- 
press, rotate,  and  relax,  advancing  by  degrees,  that  each 
handful  may  include  part  of  what  has  been  previously 
treated.  Never  stretch  the  tissues  in  opposite  direc- 
tions at  the  same  time.  Muscles  should  be  stretched 
in  the  direction  from  their  insertion  to  their  origin, 
from  extremities  toward  the  trunk,  on  the  back  from 
the  base  of  the  skull  downward,  and  away  from  the 
spinal  column.  On  the  chest,  follow  the  pectoral  mus- 
cles in  the  same  way,  and  on  the  abdomen  knead  stead- 
ily and  firmly  the  ascending,  transverse,  and  descending 
colon.  Massage  of  the  abdomen  often  relieves  dyspep- 
sia and  constipation. 

Friction  should  act  only  upon  the  skin.  If  counter- 
irritation  is  desired,  a  coarse  towel  or  a  brush  is  better 
than  the  hand.  Friction  may  be  vertical,  transverse,  or 
spiral.  Rectilinear  friction  should  be  toward  the  center 
of  circulation,  to  assist  the  venous  currents.  Thus,  on 
a  limb,  the  heaviest  strokes  should  be  upward,  the  re- 
turning ones  much  lighter.  Friction  circularly,  or  at 


88  A  TEXT-BOOK  OF  NURSING 

right  angles  to  the  long  axis,  though  sometimes  prac- 
ticed, is  awkward  and  of  little  use.  What  may  be  done 
by  such  motions  can  be  accomplished  more  effectively 
by  vertical  and  spiral  movements.  In  the  latter,  both 
hands  are  used  at  once — one  ascending  as  the  other  de- 
scends. On  the  limbs,  friction  may  be  applied  at  the 
rate  of  one  to  five  hundred  strokes  per  minute;  on  the 
body  and  thighs  the  pressure  must  be  greater,  and  the 
strokes  longer,  so  that  they  can  not  be  as  rapid.  Malax- 
ation  and  friction  may  be  used  in  alternation.  Take  a 
small  portion  of  the  body  at  a  time,  as  the  space  between 
one  joint  and  another,  and  manipulate  it  thoroughly  be- 
fore passing  to  the  next.  With  them  may  be  combined 
also  percussion  over  masses  of  muscle  and  the  various 
passive,  assistive,  and  resistive  motions. 

Muscle  hacking  consists  of  rapid  blows  delivered  per- 
pendicularly to  the  surface;  if  for  slight  superficial  stim- 
ulation, by  the  dorsal  surface  of  the  fingers;  semiflexed, 
for  deeper  effects,  by  the  ulnar  border  of  the  palm. 
Extended  vibration  is  kneading  and  striking,  with  a 
shaking  motion  added. 

Passive  motions  are  conducted  without  any  effort  on 
the  part  of  the  patient.  When  there  is  partial  control 
of  the  muscular  action,  the  operator  either  helps  or  tries 
to  hinder  the  efforts  of  the  patient,  being  careful  not  to 
overtax  his  little  strength,  and  the  exercises  are  then 
known  as  assistive  or  resistive.  Such  movements  are 
applied,  together  with  massage,  to  strengthen  weakened 
muscles  and  break  up  adhesions  in  diseased  or  anchy- 
losed  joints.  It  is  of  importance  to  know  something  of 
their  anatomical  structure  and  the  limits  of  natural 
motion. 

What  is  known  as  the  Eoman  bath  is  massage  with 
inunction.  When  there  is  a  dry  and  insufficiently  nour- 


MASSAGE  89 

ished  skin,  inunction  may  be  useful;  but  it  is  not  an 
essential  part  of  treatment  by  massage,  though  unskilled 
manipulators  often  use  oil  of  some  kind  on  their  hands 
to  avoid  chafing  the  skin. 

The  "  rest  cure  "  of  Dr.  Weir  Mitchell  is  often  em- 
ployed, in  connection  with  massage  and  electrical  stimu- 
lation, in  the  treatment  of  nervous  prostration,  where, 
with  no  apparent  organic  disease,  the  patient  yet  seems 
generally  ill.  This  condition  may  arise  from  various  , 
causes,  sometimes  from  severe  mental  strain,  unusual, 
cares,  or  great  anxiety. 

The  patient  is  kept  in  bed,  absolutely  quiet,  yTom 
three  to  six  weeks,  seeing  no  one  except  the  doctor  and 
the  nurse,  and  allowed  to  make  no  effort  of  ar^y  kind, 
mental  or  physical.  Feeding,  and  all  care  of  th<3  person 
are  attended  to  by  the  nurse.  Massage  and  Electricity 
take  the  place  of  exercise,  admii  !r>~>red  in  jeach  case 
according  to  definite  instructions.  ^  /"'the  ^'treatment 
to  be  successful,  the  rules  laid  dov  ]  '  '\  followed 

to  the  letter. 

oky  hi 

' '  The  best  doctors  in  the  world  are  Dr.  Diet,  >  j£.  Quiet,  and 
Dr.  Merry  man." — Swift. 


CHAPTER   VII 

"  Mankind,  in  the  main,  have  little  wants,  not  large, 
I,  being  of  will  and  power  to  help  in  the  main 
Mankind,  must  help  the  least  wants  first." 

Robert  Browning. 

THE  principal  elimination  of  waste  matter  from  the 
body,  is  through  the  kidneys.  These  are  two  bean- 
shapeoh  bodies,  each  about  four  inches  long,  lying  in  the 
lumbar  region,  one  on  either  side  of  the  spine.  The 
urine,  asi  it  is  excreted  by  the  kidneys,  passes  through 
two  connecting  tpfees — the  ureters — into  the  bladder, 
whence  ifo  is  j-dorsdically  discharged  through  another 
tube — thttfr  effects.  The  capacity  of  the  bladder,  fully 
distended,  vibrati>ut  three  pints.  The  urethra  in  the 
adult  femaotiora  an  inch  and  a  half  or  two  inches  in 
length,  in  t  fte  male  eight  inches. 

Urine,  iit  a  healthy  condition,  consists  of  some  960 
parts  of  wate.tr  to  40  of  solid  matter,  principally  urea — 
the  chief  was  tte  product  of  animal  life.  The  average 
quantity  of  urizttie  passed  in  the  twenty-four  hours  is  two 
and  a  half  pints,st  or  forty  fluid  ounces.  This  will  contain 
from  450  to  600  >r  grains  of  urea,  besides  a  small  propor- 
tion of  uric  acid,^  and  various  phosphates,  urates,  and 
chlorides.  It  is  trb  insparent,  of  pale  amber  color,  hav- 
ing a  characteristic  \tflroma,  an  acid  reaction,  and  a  spe- 
cific gravity  of  1020.  \ 

There  may  be  considerable  deviations  from  the  above 

standard,  even  strictlyVtwithin  the  limits  of  health.  'The 

90 


URINE  91 

quantity  will  vary  in  proportion  to  the  amount  of  fluid 
taken  into  the  system,  and  to  the  activity  of  the  skin. 
When  there  is  free  perspiration,  less  water  is  left  to  be 
carried  off  by  the  kidneys,  and,  consequently,  the  urine 
is  less  abundant,  darker  in  color,  and  of  greater  specific 
gravity,  owing  to  the  increased  proportion  of  solid  mat- 
ter. The  specific  gravity  may  vary  from  1010  to  1035 
without  indicating  any  departure  from  health.  The  re- 
action may  for  a  time  become  neutral  or  even  alkaline 
after  a  meal,  owing  to  the  character  of  the  food  taken. 
Diminished  transparency  may  be  due  to  the  presence 
of  the  earthy  phosphates,  or  the  mixed  urates  of  sodium, 
potassium,  calcium,  and  magnesium,  or  to  mucus  from 
the  genito-urinary  tract. 

The  same  causes  of  variation  may  exist  to  an  ex- 
treme degree  in  sickness.  The  quantity  may  be  dimin- 
ished to  two  or  increased  to  two  hundred  ounces.  The 
color  may  be  affected  either  by  diminution  of  the  nor- 
mal coloring  matters  or  by  the  addition  of  abnormal 
ones.  Opacity  may  be  occasioned  by  the  presence  of 
pus.  Blood  gives  a  characteristic  smoky  hue  to  acid 
urine;  with  an  alkaline  reaction,  it  is  more  nearly  red. 
Urine  containing  blood  enough  to  be  readily  recogniz- 
able as  such  is  probably  albuminous.  Bile  imparts  a 
greenish  tinge,  often  seen  with  jaundice.  In  some  cases 
the  urine  becomes  viscid  or  glutinous;  in  a  variety 
known  as  chylous  urine,  there  is  an  increased  consist- 
ency, owing  to  an  addition  of  molecular  fat.  In  hys- 
teria, alcoholism,  anaemia,  and  convalescence  from 
acute  diseases,  the  urine  may  be  expected  to  be  pale  and 
abundant.  In  the  early  stage  of  acute  fever  the  specific 
gravity  is  likely  to  be  high,  as  a  large  amount  of  solid 
matter  is  excreted.  Lowered  specific  gravity  is  most 
significant  when  it  attends  diminished  quantity  of  urine. 


92  A  TEXT-BOOK  OF  NURSING 

In  diabetes  mellitus,  the  specific  gravity  of  the  urine 
may  be  as  high  as  1050,  while  at  the  same  time  the 
quantity  is  largely  increased.  This  is  due  to  the  pres- 
ence of  sugar.  In  the  disease  known  as  diabetes  insipi- 
dus,  or  polyuria,  there  is  an  abundant  flow  of  pale  urine, 
but  it  contains  no  sugar  or  albumin,  and  the  specific 
gravity  is  proportionately  low. 

It  has  already  been  noted  that  the  food  taken  may 
be  of  a  sort  to  occasion  temporary  variations  in  the 
character  of  the  urine.  Certain  drugs  also  produce 
specific  effects  upon  it.  Turpentine  taken  internally 
gives  to  the  urine  an  odor  resembling  that  of  violets. 
It  sometimes  increases  the  flow,  and  sometimes  causes 
retention.  Cantharides  may  also  cause  retention,  or 
slow  and  painful  passage  of  urine,  known  as  strangury. 
Dark,  smoky  urine  is  one  of  the  early  symptoms  of  car- 
bolic acid  or  iodoform  poisoning.  Santonin  gives  a 
brilliant  yellow  color;  rhubarb  or  senna,  a  reddish  yel- 
low; cubebs,  copaiba,  and  sandal  oil,  each  imparts  its 
peculiar  odor.  Medicines  which  increase  the  quantity 
of  urine  are  called  diuretics. 

It  will  be  seen  that  many  important  indications  may 
be  derived  from  careful  observation  and  examination  of 
the  urine.  The  nurse  should  always  be  able  to  report 
the  frequency  of  micturition,  the  quantity  passed,  and 
any  evident  peculiarity.  A  specimen  for  examination 
should  be  taken  either  from  the  total  accumulation  of 
the  twenty-four  hours,  or  from  that  passed  before 
breakfast.  In  warm  weather  even  normal  urine  can  not 
stand  for  twenty-four  hours  without  becoming  decom- 
posed. It  is  best  kept  in  a  tall,  narrow  glass,  tapering 
toward  the  bottom,  covered  with  a  loose  paper  cap  to 
keep  out  the  dust.  In  getting  a  specimen  for  the  doc- 
tor, or  for  your  own  thorough  examination,  care  must 


URINE  93 

be  taken  to  have  it  free  from  all  impurities.  Six  or 
eight  ounces  will  be  wanted.  Put  it  in  a  clean  bottle 
with  a  clean  cork,  and  label  distinctly  with  the  name  of 
the  patient,  the  date,  and  the  full  quantity  of  which  it 
is  a  sample.  It  may  be  necessary  to  use  the  catheter  in 
order  to  obtain  it  free  from  mucus;  this  is  especially 
true  in  the  case  of  women  with  leucorrhcea  or  vaginal 
haemorrhage.  Whether  or  not  there  is  any  appreciable 
sediment,  a  portion  should  be  set  aside  for  twelve  hours, 
in  which  time  sediment  sufficient  for  microscopic  ex- 
amination may  be  deposited.  Note  whether  the  urine 
is  turbid  when  first  passed,  or  only  becomes  so  after 
standing,  the  quantity  and  character  of  the  sediment, 
and  whether  it  floats  or  sinks. 

To  determine  the  reaction,  test  with  litmus  paper. 
If  acid,  it  will  turn  the  blue  red;  if  alkaline,  the  red  to 
blue;  if  neutral,  it  will  have  no  effect  upon  either. 
Urine  having  an  acid  or  neutral  reaction  may  turn  al- 
kaline after  standing,  but  that  which  is  alkaline  in  the 
beginning  never  becomes  acid.  After  standing  a  short 
time  at  a  moderate  temperature  the  acidity  often  in- 
creases, but  after  a  longer  time,  and  especially  in  warm 
weather,  the  reaction  becomes  alkaline,  with  an  ammo- 
niacal  odor  and  a  precipitation  of  sediment.  Alkalinity, 
owing  to  the  presence  of  ammonia,  may  be  distinguished 
from  that  due  to  the  fixed  alkalies,  potash,  or  soda,  by 
drying  the  litmus  paper  which  has  been  changed  by  it. 
If  the  alkali  is  volatile,  it  will  disappear,  and  the  paper 
resume  its  red  hue;  otherwise,  the  blue  will  be  perma- 
nent. 

The  urinometer  should  have  been  first  tested  with 
distilled  water,  into  which  it  should  sink  to  1000.  The 
urine  should  be  well  shaken,  and,  if  cloudy,  filtered. 
The  glass  containing  it  should  not  be  too  small,  as  the 


94  A  TEXT-BOOK  OF  NURSING 

urinometer  must  not  touch  its  sides.  Drop  it  in  the 
middle,  and  note  carefully  the  point  at  which  it  rests. 

Foreign  matters  in  the  urine  may  be  either  sedimen- 
tary or  in  solution.  The  most  common  sediment  is  com- 
posed of  the  urates  and  phosphates.  They  subside  into 
a  white  or  pink  deposit.  They  may  be  distinguished 
from  each  other  by  boiling  a  little  of  the  urine  in  a 
test-tube  over  the  spirit-lamp,  the  urates  being  dissi- 
pated by  the  heat,  while  the  phosphates  are  precipitated. 
The  latter  may  be  dissipated  by  adding  a  few  drops  of 
nitric  acid.  Mucus  is  unaffected  by  heat,  acids,  or  alka- 
lies. Pus  will  be  deposited  as  an  opaque  white  sediment, 
sinking  rapidly  so  long  as  the  reaction  is  acid  and  there 
is  no  mucus  in  which  it  may  be  suspended.  It  resem- 
bles the  urates,  but  is  not,  like  them,  dissolved  on  the 
application  of  heat.  In  Bright's  disease  albumin  is 
present,  and  often  casts  of  the  tubules  of  the  kidney. 
The  latter  are  evident  only  upon  microscopic  examina- 
tion. Mucus  and  pus  also  can  only  be  positively  identi- 
fied by  the  microscope. 

Urine  to  be  tested  for  albumin  should  first  be  fil- 
tered, if  not  perfectly  clear.  Fill  a  test-tube  to  one  third 
its  depth,  and,  if  the  urine  is  not  of  distinctly  acid  re- 
action, add  one  or  two  drops  of  acetic  acid  to  make  it  so. 
Boil  for  a  moment  and  then  hold  it  up  to  the  light.  Any 
opacity  appearing  will  be  due  either  to  albumin  or  earthy 
phosphates.  If  the  latter,  it  will  disappear  upon  the  addi- 
tion of  a  few  drops  of  nitric  acid.  If  the  fluid  remains 
quite  clear  after  boiling,  set  it  aside  for  twelve  hours, 
in  which  time  a  sediment  may  be  deposited.  Anything 
except  albumin  will  disappear  upon  a  second  boiling. 

If  the  proportion  of  albumin  is  but  small,  it  may  be 
held  in  solution  by  a  slight  excess  of  acid,  on  which  ac- 
count the  following  treatment  is  perhaps  more  reliable: 


URINE  95 

Fill  a  test-tube  to  the  depth  of  half  an  inch  with 
pure  nitric  acid.  Add  to  this,  by  means  of  a  small 
glass  tube,  an  equal  quantity  of  clear  urine,  putting  it 
in  so  gently  that  it  will  not  mix  with,  but  just  overlie, 
the  acid.  This  can  be  done  by  inclining  the  test-tube 
and  gently  rotating  the  pipette.  If  there  is  albumin  in 
the  urine,  it  will  appear  at  the  surface  of  contact  as  a 
white  zone,  of  varying  thickness  in  proportion  to  its 
quantity.  A  similar  white  band  may  be  formed  by  the 
mixed  urates,  if  present  in  excess;  but  this  may  be  dis- 
sipated by  heat,  while  the  albumin  will  be  still  further 
defined  by  it. 

Heat  precipitates  albumin. 

"  phosphates. 

"     dissolves  urates. 
Nitric  acid  precipitates  albumin. 

"        "  "  urates. 

"        "  "  dissolves  phosphates. 

Pale  urine  produced  in  large  quantity,  and  at  the 
same  time  of  a  high  specific  gravity,  should  be  tested 
for  sugar.  A  specific  gravity  of  more  than  1030  is 
sufficient  to  excite  suspicion  of  its  presence.  If  there 
is  albumin  in  the  urine,  it  should  first  be  removed  by 
boiling  and  filtration. 

A  pretty  and  delicate  test  for  sugar  is  by  means  of 
Fehling's  solution,  of  sulphate  of  copper  and  tartrate  of 
sodium.  This  needs  to  be  kept  tightly  corked,  and  in 
the  dark,  as  it  is  decomposed  by  the  action  of  light. 
Dilute  with  five  times  its  bulk  of  water,  and  boil.  If  a 
precipitate,  or  change  of  color,  appears  on  boiling,  the 
solution  is  worthless,  and  a  fresh  one  must  be  prepared. 
Add,  drop  by  drop,  an  equal  volume  of  the  suspected 
urine,  when,  if  sugar  is  present,  a  precipitate  will  ap- 


96  A  TEXT-BOOK  OF  NURSING 

pear,  varying  in  color  from  light-yellow  to  orange-red, 
according  to  the  quantity  of  sugar  present. 

An  absence  of  the  urinary  excretion,  owing  to  a  fail- 
ure of  the  kidneys  to  act,  is  known  as  suppression.  It 
is  less  common  than  retention — the  failure  to  expel  that 
which  is  in  the  bladder.  The  latter  may  be  referred  to 
various  causes.  The  bladder  may  be  paralyzed,  or  the 
senses  dulled,  so  that  there  is  no  desire  to  pass  urine, 
even  when  the  bladder  is  full,  or  there  may  be  a  nervous 
contraction  of  the  urethra,  resulting  in  an  inability  to 
do  so  even  when  the  inclination  is  felt.  When  no  urine 
has  been  passed  for  some  time,  if  there  is  pain  on  pres- 
sure above  the  pubes,  a  dull  instead  of  a  clear  sound  on 
percussion,  and  if  the  outline  of  the  bladder  can  be  dis- 
tinctly seen,  it  may  be  safely  assumed  to  be  full,  and  the 
use  of  the  catheter  is  indicated.  Cystitis  is  an  inflam- 
mation of  the  bladder,  marked  by  peculiarly  distressing 
pain;  it  is  often  the  result  of  taking  cold,  and  is  a  fre- 
quent complication  of  uterine  diseases.  Incontinence  of 
urine  arises  from  weakness  of  the  neck  of  the  bladder, 
rendering  it  unable  to  restrain  its  contents;  it  is  most 
frequent  in  children.  Apparent  incontinence  may  be 
really  retention  with  overflow,  caused  by  the  over-dis- 
tention  of  the  bladder,  and  consequent  muscular  strain. 
Catheterization  may  be  called  for  even  when  there  is 
constant  slight  passage  of  urine.  In  all  cases  of  incon- 
tinence special  care  is  needed  to  keep  the  parts  clean 
and  to  prevent  excoriation,  by  frequent  bathing  and 
the  application  of  ointments.  Rubber  urinals  are  some- 
times used. 

Whenever,  from  any  cause,  a  patient  is  unable  to 
pass  urine  voluntarily,  the  catheter  should  be  used 
every  six  or  eight  hours.  If  it  is  properly  introduced, 
and  no  urine  can  be  drawn,  suppression  may  be  inferred. 


URINE  97 

This  is  a  very  serious  symptom,  for,  if  the  system  can 
not  be  relieved  of  its  waste  product,  the  urea  is  soon 
absorbed  into  the  blood,  and  uraemia,  a  dangerous  form 
of  poisoning,  results.  Hot  applications  over  the  kidneys 
will  sometimes  excite  them  to  action.  So  when  the 
difficulty  is  retention  only,  hot  applications  over  the 
bladder  may  relieve  it;  they  usually  will  with  children. 
A  hot  sponge  between  the  thighs  may  be  effective.  The 
sound  of  running  water  will  sometimes  overcome  reten- 
tion due  to  nervousness.  When  the  use  of  the  catheter 
in  the  female  is  imperative,  proceed  as  follows:  Oil  the 
instrument  with  the  finger.  Have  the  patient  flat  on 
the  back,  if  possible,  with  the  thighs  slightly  separated. 
Find  the  vagina  as  a  landmark,  and  just  above  it  will 
be  felt  a  slight  prominence.  Immediately  above  this 
is  the  depression  which  marks  the  urethral  opening. 
Into  this  slide  very  gently  the  point  of  the  catheter, 
being  careful  that  it  does  not  slip  into  the  vagina.  It 
should  not  be  pushed  far  enough  to  strike  the  walls  of 
the  bladder.  As  soon  as  the  cavity  is  reached,  the  end 
of  the  catheter  will  move  freely,  and  the  urine  will 
flow  through  it  into  the  receptacle  provided.  If  the 
flow  ceases  before  a  reasonable  quantity  has  been  passed, 
withdraw  the  instrument  slightly,  turn  it,  then  push  it 
a  little  farther  in  than  before,  when  it  may  begin  again. 
After  the  bladder  is  emptied,  withdraw  the  catheter 
as  gently  as  it  was  introduced.  In  no  case  use  force. 
While  removing  the  catheter,  keep  a  finger  over  the 
open  end,  so  that  the  few  drops  which  it  contains  will 
not  fall  on  the  bed.  If,  from  over-sensitiveness  of  the 
parts,  the  passage  of  the  catheter  causes  great  irrita- 
tion, it  may  be  allayed  by  applying  previously  a  little 
belladonna  or  cocaine  ointment. 

A  distended  bladder  should  not  be  too  rapidly  emp- 


98  A  TEXT-BOOK  OF  NURSING 

tied  by  catheter,  as  there  is  danger  of  cystitis  from  the 
sudden  collapse  of  its  walls.  When  it  is  very  full,  draw 
only  a  portion  of  the  contents  at  first  introduction  of 
the  catheter,  and  repeat  the  process  soon. 

To  pass  the  catheter  skillfully  is  an  important  ac- 
quisition. It  may,  in  the  female  subject,  be  done  en- 
tirely under  the  bedclothes;  no  exposure  of  the  pa- 
tient's person  is  necessary,  but  there  should  be  no  hesi- 
tation in  using  the  sense  of  sight  when  there  is  any 
difficulty  in  finding  the  meatus  by  touch.  Do  not  even 
then  expose  the  patient  unnecessarily,  but  have  the 
limbs  flexed  as  she  lies  on  her  back,  and  cover  each  with 
a  blanket,  leaving  only  the  vulva  visible.  In  all  cases 
of  operation  on  the  perinaeum,  vulva,  vaginal  walls,  or 
urethra,  the  catheter  must  be  introduced  by  sight,  to 
avoid  any  possible  damage  to  the  stitches.  This  is  also 
preferable  after  labor.  Aseptic  precautions  are  also 
necessary.  The  catheter  should  be  boiled  before  use, 
and  kept  in  a  basin  containing  mercuric  bichloride 
1-3000.  It  is  convenient  also  to  have  in  this  basin  a 
number  of  cotton  swabs.  The  parts  should  be  washed 
carefully  with  the  same  solution,  the  labia  being  sepa- 
rated, and  any  wound  receiving  special  attention.  If 
the  catheter  should  happen  to  slip  into  the  vagina,  re- 
move, and  wash  it  again  before  inserting  in  the  urethra. 
When  the  urine  has  ceased  to  flow,  the  finger  placed 
over  the  open  end  of  the  catheter  and  held  firmly  will 
prevent  the  urine  escaping  from  the  eye  of  the  instru- 
ment as  it  is  withdrawn.  The  urethral  opening  is  now 
again  sponged  dry  with  one  of  the  cotton  swabs.  The 
catheter  is  to  be  washed  and  replaced  in  the  bichloride 
solution. 

It  is  but  rarely  that  the  nurse  will  have  need  to  pass 
the  catheter  upon  a  male,  but  it  will  occasionally  occur, 


URINE  99 

and  she  should  know  how  to  do  it.  The  patient  may 
be  standing,  but  it  is  better  to  have  him  lying  on  his 
back,  the  knees  drawn  up,  slightly  separated,  and  the 
shoulders  raised.  The  external  generative  organs  must 
be  completely  exposed,  and  the  nurse  should  stand  on 
the  patient's  left.  The  penis  must  be  raised  to  an  angle 
of  about  60°  with  the  body,  thus  effacing  the  anterior 
curve  of  the  urethra,  using  the  second  and  third  fingers 
of  the  left  hand,  keeping  its  palm  upward.  The  thumb 
and  first  finger  being  free  are  used  to  draw  back  the 
prepuce  and  "  separate  the  lips  of  the  meatus."  The 
catheter  should  be  warmed,  then  oiled  and  held  lightly 
but  firmly  between  the  thumb,  first  and  second  fingers 
of  the  right  hand,  as  a  pen  is  held — the  shaft  of  the 
catheter  corresponding  to  the  fold  between  the  abdo- 
men and  the  left  thigh.  The  catheter  should  be  intro- 
duced with  slight  force,  and  slowly.  If  properly  started 
its  own  weight  is  nearly  enough  to  effect  a  passage. 
Should  it  meet  with  resistance,  withdraw  it  a  little  and 
then  advance,  changing  slightly  the  direction  of  its 
point.  As  the  catheter  passes  along  the  first  two  inches 
of  the  urethra,  the  point  should  be  directed  slightly  to 
the  lower  surface  to  avoid  the  lacuna  magna,  a  large 
gland  in  this  location.  It  is  wise  to  continue  this  in- 
clination until  the  angle  of  the  scrotum  and  penis  has 
been  passed.  Then  it  changes  and  the  tendency  should 
be  toward  the  upper  surface,  thus  escaping  the  sinus  of 
the  bulb.  When  it  lies  beneath  the  pubes  the  shaft  is 
brought  around  parallel  to  the  surface  of  the  abdomen, 
and  in  the  median  line.  Elevate  the  handle  until  per- 
pendicular, and  press  with  the  free  hand  upon  the 
mons  veneris,  and  the  root  of  the  penis,  thus  extending 
the  suspensory  ligament.  The  point  will  then  gen- 
erally glide  into  the  bladder. 


100  A  TEXT-BOOK  OP  NURSING 

The  flexible  rubber  catheter  is  the  most  convenient, 
and  least  likely  to  hurt  the  patient.  No.  7  is  a  good 
size  for  ordinary  cases.  After  each  use  it  should  be 
thoroughly  cleaned  and  disinfected.  Let  a  stream  of 
water  run  through  it  in  both  directions,  first  from  the 
eye  downward,  lest  any  sediment  be  driven  down  into 
the  point.  It  may  be  boiled  without  injury,  and  soaked 
in  bichloride.  If  kept  in  this  solution,  it  should  be 
rinsed  before  using.  A  glass  catheter  is  preferred  by 
many  gynaecologists,  and  has  the  advantage  of  being 
most  easily  cleaned,  and  showing  most  readily  the  pres- 
ence of  any  foreign  matter. 

In  cases  of  cystitis,  the  bladder  will  often  have  to 
be  washed  out.  For  this  purpose  a  double  catheter  or 
an  especially  designed  syringe  is  used.  Or  it  may  be 
equally  well  done  by  fitting  a  longer  rubber  tube  over 
one  end  of  a  piece  of  glass  tubing,  the  other  end  being 
inserted  into  the  ordinary  catheter,  which  is  then  intro- 
duced in  the  usual  way.  The  bladder  being  first  emp- 
tied, pour  into  the  tube,  through  a  glass  funnel,  the 
water,  or  whatever  fluid  is  ordered,  a  pint  at  a  time,  at 
a  temperature  of  100°  F.  Lower  the  tube  and  let  it 
run  off,  and  repeat  the  process  until  it  runs  clear. 
Never  try  to  use  a  Davidson  syringe  for  this  pur- 
pose, as  each  impulse  will  give  pain,  but  a  fountain 
syringe  with  glass  catheter  attached  makes  an  excel- 
lent apparatus,  both  having  first  had  boiling  water, 
and  some  disinfecting  solution  passed  through 
them.  If  the  catheter  is  not  a  double  one,  it 
must  be  disconnected  each  time,  to  allow  the  fluid  to 
escape. 

Further  elimination  of  waste  matter  takes  place 
through  the  gastro-intestinal  tract,  beginning  with  the 
disintegration  of  food  in  the  stomach. 


ENEMATA  101 

The  intestinal  canal  is  formed  by  the  folds  of  a 
single  long  tube,  some  twenty-five  or  thirty  feet  in 
length.  That  part  of  it  nearest  the  stomach  is  called 
the  small  intestine — various  subdivisions,  respectively, 
the  duodenum,  jejunum,  and  ileum;  the  last  five  or  six 
feet  are  of  much  greater  diameter,  and  are  therefore 
spoken  of  as  the  large  intestine.  This  also  is  subdivided 
into  the  caecum,  the  colon — ascending,  transverse,  and 
descending — and  the  rectum.  It  is  not  directly  con- 
tinuous with  the  small  intestine.  The  enlargement  is 
abrupt,  at  right  angles  to  the  ileum,  and  separated  from 
it  by  a  valve.  This  ileo-caecal  valve  allows  free  passage 
to  the  contents  of  the  small  intestine,  but  firmly  resists 
pressure  from  the  caecal  side.  At  the  end  of  the  caecum 
is  a  small  closed  tube,  called  the  vermiform  appendix, 
the  uses  of  which  are  unknown.  It  is  frequently  the 
seat  of  serious  inflammation  known  as  appendicitis.  A 
continual  motion  is  kept  up  in  the  intestines,  by  means 
of  which  their  contents  are  propelled  along.  These 
movements  are  termed  peristaltic.  The  process  of  di- 
gestion is  completed  in  the  small  intestine;  whatever 
passes  beyond  this  is  merely  the  waste  and  innutritions 
residue  of  the  food,  and  undergoes  no  further  digestive 
action.  The  intestines  and  all  the  other  abdominal  vis- 
cera are  bound  together  and  held  in  place  by  a  strong 
membrane,  the  peritonaeum. 

An  enema,  or  clyster,  is  a  fluid  preparation  for  injec- 
tion into  the  rectum.  Large  ones  are  administered  by 
means  of  a  bulb  or  fountain  syringe.  For  small  ones 
a  syringe  of  hard  rubber  is  to  be  preferred.  Enemata 
may  be  used  to  secure  or  control  evacuations  of  the 
bowels,  to  obtain  remedial  effect,  local  or  general,  or  for 
the  administration  of  nourishment.  According  to  the 
purpose  for  which  they  are  given,  they  may  be  classified 


102  A  TEXT-BOOK  OF  NURSING 

as  purgative,  emollient,  astringent,  sedative,  antbelmin- 
tic,  stimulant,  nutritive,  etc. 

Purgative  enemata  are  in  general  use  for  the  relief 
of  constipation.  They  produce  the  desired  result  not 
simply  by  washing  out  the  accumulated  fecal  matter, 
but  by  distention  of  the  rectum  and  lower  part  of  the 
bowel,  occasioning  a  reflex  stimulation,  and  increased 
peristaltic  action  of  the  whole  intestinal  tract.  They 
are  found  to  act  efficiently  even  when  the  matter  is 
lodged  high  up  in  the  intestine,  beyond  the  ileo-caecal 
valve.  A  small  enema  often  fails  when  a  large  one 
would  be  operative.  To  an  adult  should  be  given  from 
one  to  four  pints;  a  child  requires  but  half  as  much, 
and  for  an  infant  one  or  two  ounces  will  be  sufficient. 
Having  carefully  protected  the  bed,  place  the  patient 
on  the  left  side,  with  the  knees  flexed.  In  an  obstinate 
case,  an  advantage  will  be  gained  by  adopting  the  Sims, 
or  the  knee-chest  position.  If  the  rectum  is  packed,  it 
may  be  necessary  to  remove  some  of  the  fecal  matter 
with  the  fingers  before  the  tube  of  the  syringe  can  be 
introduced.  Ordinarily  the  rectum  will  be  found  emp- 
ty, the  accumulation  being  in  the  lower  part  of  the 
colon  above  the  sigmoid  flexure. 

Pass  the  fluid  several  times  through  the  syringe  to 
expel  the  air  from  it;  oil  the  nozzle  and  insert  it  very 
gently  upward,  slightly  backward,  and  toward  the  left. 
Under  no  circumstances  use  force.  See  that  the  end 
of  the  tube  moves  freely  in  the  rectum,  neither  pressed 
against  the  sacrum  nor  imbedded  in  a  fecal  mass.  Give 
the  injection  very  slowly;  sudden  distention  of  the  rec- 
tum will  produce  an  immediate  and  imperative  desire 
for  relief.  It  is  a  process  about  which  it  is  impossible 
to  hurry.  If  the  patient  complains  greatly  of  pain,  rest 
a  little;  after  a  delay  of  a  few  moments  you  can  usually 


ENEMATA  103 

go  on  without  causing  distress.  The  anus  may  be  sup- 
ported by  a  folded  towel,  or,  where  there  is  little  con- 
trol of  the  sphincter,  two  or  three  fingers  will  have  to  be 
passed  into  the  rectum  by  the  side  of  the  tube.  After 
the  desired  amount  has  been  injected,  remove  the  tube 
gently,  and,  continuing  to  support  the  anus,  keep  the 
patient  perfectly  quiet  for  ten  or  fifteen  minutes.  If  a 
full  enema  can  be  retained  for  this  length  of  time, 
there  will  in  ordinary  cases  be  little  doubt  of  a  satisfac- 
tory result.  A  bulb  syringe,  as  the  Davidson,  is  perhaps 
the  best  for  giving  a  purgative  enema,  as  the  force  of 
the  flow  can  be  regulated  by  hand  and  arrested  tem- 
porarily if  desired.  Nothing  requires  more  care  than 
the  proper  administration  of  enemata,  and  the  most 
frequent  reason  for  failure  is  that  the  nurse  does  not 
take  time  enough.  A  most  effective  method  is  to  throw 
the  fluid  high  up  into  the  bowel  through  a  soft  rubber 
tube  connected  with  the  syringe.  This  is  known  as  a 
high  enema.  The  tube  should  carry  the  fluid  above  the 
sigmoid  flexure,  and  must  of  course  be  introduced  with 
great  care.  A  No.  12  male  elastic  catheter  can  be  ob- 
tained of  the  druggist.  It  should  first  be  softened  by 
dipping  it  in  warm  water.  Water  alone  may  be  used 
for  the  injection,  or,  where  something  more  stimulating 
is  called  for,  various  medicaments  are  added,  as  soap, 
salt,  olive  or  castor  oil,  ox-gall,  etc.  A  drachm  of  glyc- 
erin will  add  greatly  to  the  action  of  an  enema,  or  a 
saturated  solution  of  Epsom  or  Rochelle  salts  may  be 
used.  In  obstinate  constipation  and  intestinal  obstruc- 
tion nothing  is  so  effective  as  a  high  enema  containing 
5  xij-3  XVJ  of  molasses.  For  ordinary  cases  soap-suds 
are  excellent  and  convenient.  An  enema  of  this  sort 
may  be  rendered  more  certain  in  its  action  by  the  addi- 
tion of  a  couple  of  ounces  of  oil  and  half  an  ounce  of 


104  A  TEXT-BOOK  OP  NURSING 

turpentine;  these,  with  a  small  quantity  of  the  soap- 
suds, should  be  first  injected,  and  followed  by  the  bulk 
of  the  fluid.  An  injection  of  olive  oil,  §  iv-vj,  may  be 
given  half  an  hour  before  one  of  water,  and  allowed 
to  remain,  in  order  to  soften  the  fecal  mass.  After  any 
operation  upon  the  genital  organs  or  the  anus,  where 
there  is  likely  to  be  a  strain  upon  sutures,  such  an 
enema  may  be  given  before  each  movement.  Oil  should 
always  be  warmed,  as,  when  cold,  it  is  too  thick  to  pass 
through  the  syringe  readily.  Another  enema  exceed- 
ingly useful  for  softening  scybalous  masses  in  the  rec- 
tum is  of  a  solution  of  inspissated  ox-gall.  It  should 
be  retained  for  about  an  hour,  and  then  be  followed  by 
a  large  enema  of  soap-suds.  This  is  used  especially 
after  operation  for  laceration  of  the  perinseum  through 
the  sphincter. 

The  habitual  use  of  large  evacuant  enemata  is  to  be 
discouraged,  as  causing  undue  distention  and  a  some- 
what torpid  condition  of  the  bowels. 

As  to  the  best  temperature  for  evacuant  enemata, 
authorities  differ.  Hot  or  cold  water  will  naturally  ex- 
cite the  intestines  to  more  vigorous  action  than  water 
of  the  same  temperature  as  the  body,  but  not  so  much 
of  it  can  be  taken.  Either  may  be  used  without  incon- 
venience to  the  patient.  The  daily  injection  of  a  pint  of 
cold  water  is  often  advised  in  case  of  constipation  at- 
tended by  bleeding  haemorrhoids. 

Injections  of  ice-water  are  sometimes  given  to  check 
haemorrhage  from  the  bowels. 

When  there  is  an  irritable  condition  of  the  mucous 
membrane,  enemata  of  a  more  soothing  nature  are  indi- 
cated. Thin  gruel  is  often  used,  or  a  decoction  of  flax- 
seed,  starch,  or  barley.  Emollient  enemata  should  al- 
ways be  warm. 


ENEMATA  105 

Hot  rectal  injections  are  used  to  relieve  pelvic  con- 
gestion, also  in  dysentery,  for  cleansing  and  relieving 
inflammation. 

For  the  rectal  douche,  a  fountain  syringe  should  be 
used  with  rectal  or  stomach-tube  attached.  The  pa- 
tient should  lie  on  the  back,  the  knees  well  flexed,  with 
a  small  pillow  under  the  hips,  to  insure  the  passing  of 
the  liquid  backward  and  upward. 

Anthelmintic  enemata  are  given  to  destroy  worms. 
Only  a  small  quantity  need  be  used :  for  an  adult  half  a 
pint  is  sufficient,  for  a  child  still  less.  The  remedy 
to  be  employed  will  be  prescribed  by  the  physician  to 
suit  the  case.  Salt,  quassia,  aloes,  tincture  of  iron,  and 
weak  carbolic  acid  are  among  those  used.  Avoid  mak- 
ing the  solution  too  concentrated,  as  it  may  excite  in- 
flammation. 

To  check  diarrhoea  enemata  of  starch  are  frequently 
given,  thin  enough  to  pass  readily  through  the  syringe, 
to  which  has  been  added  a  prescribed  quantity  of  lauda- 
num, usually  about  thirty  drops  to  two  fluid  ounces  of 
starch.  These  may  be  ordered  after  each  movement,  or 
regularly  every  few  hours.  The  action  is  at  once  seda- 
tive and  astringent.  Other  astringents,  as  sulphate  of 
copper  or  acetate  of  lead,  are  sometimes  similarly  em- 
ployed. 

Sedatives  are  given  by  rectum  for  the  relief  of  pain, 
especially  in  the  region  of  the  pelvis.  It  takes,  as  a 
rule,  a  third  more  of  any  drug  than  the  dose  given  by 
mouth  to  produce  the  same  effect  per  rectum,  and  three 
times  as  long  to  produce  the  effect.  Any  rectal  injec- 
tion intended  to  be  retained  must  be  given  very  slowly, 
in  quantity  not  exceeding  three  ounces,  and  of  a  tem- 
perature not  less  than  100°  Fahr.  Quiet  must  be  en- 
forced for  some  time  after  it  is  taken.  The  best  instru- 


106  A  TEXT-BOOK  OF  NURSING 

ment  is  a  hard-rubber  syringe  holding  the  exact  quan- 
tity, to  which  a  long  flexible  rectal  tube  is  attached. 
A  high  enema  can  be  given  oftener  and  retained  longer 
than  when  the  short  tube  only  is  used.  Care  must  be 
taken  not  to  introduce  air  at  the  time  of  the  adminis- 
tration of  the  enema.  An  ordinary  stomach-tube  of 
medium  size  is  an  excellent  appliance  with  which  to 
give  the  enema,  and,  in  addition,  is  much  more  free 
from  danger  than  the  hard  rectal  tubes.  A  piece  of 
rubber  tubing  may  be  attached  to  the  stomach-tube,  and 
to  this  a  small  funnel.  The  fluid  to  be  administered 
is  poured  into  the  funnel,  and  allowed  to  appear  at  the 
eye  of  the  stomach-tube;  this  will  exclude  the  air.  The 
tube  is  now  held  firmly,  so  that  the  fluid  may  not  es- 
cape. It  should  have  been  previously  lubricated,  and 
after  being  introduced  into  the  rectum  for  a  distance 
of  six  or  seven  inches,  the  fluid  is  allowed  to  flow,  the 
funnel  being  elevated.  Especially  do  these  directions 
apply  to  nutrient  enemata,  which  are  used  when  suffi- 
cient food  can  not  be  received  or  disposed  of  by  the 
stomach.  The  possibility  of  nourishing  in  this  way  is 
often  the  means  of  saving  life.  Any  highly  concen- 
trated liquid  food  may  be  given.  Beef-extracts  are 
most  often  used.  Defibrinated  blood  has  been  thought 
valuable.  Brandy,  or  some  other  form  of  alcoholic 
stimulant,  is  often  given,  together  with  the  nourish- 
ment, but  it  is  so  irritating  that  its  use  can  not  be  long 
continued.  As  food  given  by  rectum  has  not  been 
through  the  regular  digestive  processes,  it  must,  to  be 
easily  assimilated,  be  subjected  to  artificial  digestion; 
therefore,  pepsin  or  pancreatic  extract  is  commonly 
added  to  it.  Solutions  having  a  slightly  acid  reaction 
are  absorbed  with  the  greatest  facility.  These  injec- 
tions should  not  be  given  too  frequently,  or  they  may 


SUPPOSITORIES      .  107 

fail  to  be  retained;  absorption  is  slow,  and  the  rectum 
not  very  tolerant  of  foreign  matter.  Once  in  five  hours 
is  often  enough,  and  three  ounces  the  maximum  quan- 
tity. If  so  much  can  not  be  borne,  try  two  or  one  at  a 
time.  Before  giving  a  nutrient  enema,  it  is  important 
to  ascertain  whether  or  not  the  rectum  contains  faeces. 
If  it  is  not  found  empty,  it  will  be  necessary  to  give 
first  a  purgative  enema.  It  will  often  be  found  that 
after  the  rectum  has  been  filled  several  times,  the  non- 
absorbed  residue  will  decompose  and  of  itself  cause  irri- 
tation. This  can  be  avoided  if  the  rectum  is  occasion- 
ally irrigated. 

After  using  a  syringe,  clean  it  by  letting  plenty  of 
warm  water  run  through  it,  wipe  it  on  the  outside,  and 
hang  it  up  by  the  extreme  end  to  drain.  Never  put  it 
away  in  the  box  wet.  A  hard-rubber  syringe  shrinks 
in  drying,  and  if  left  long  unused  will  be  apt  to  leak, 
but  this  can  be  remedied  by  soaking  in  hot  water.  A 
bed-pan  should  always  be  warmed  before  use  by  dipping 
in  hot  water.  Dry  it  carefully,  and,  if  any  difficulty 
is  found  in  adjusting  it,  oil  the  edges.  Have  a  little  dis- 
infecting solution  in  it.  For  a  very  thin  patient  pad 
the  edges. 

Suppositories  are  solid  bodies  for  introduction  into 
the  rectum,  answering,  to  some  extent,  the  same  pur- 
poses as  enemata.  They  are  of  various  sizes,  conical  or 
spherical  in  form,  and,  while  firm  enough  to  retain 
their  shape  under  ordinary  conditions,  are  sufficiently 
soft  to  melt  under  the  heat  of  the  body.  They  are 
usually  made  of  cacao  butter,  in  which  some  medicinal 
agent  is  incorporated.  They  have  the  advantage  of 
facility  of  application,  and,  being  of  little  bulk,  are 
easily  retained.  Opium  is  often  given  in  this  form  for 
the  relief  of  local  pain  or  diarrhoea.  Suppositories  of 


108 


A  TEXT-BOOK  OF  NURSING 


soap  or  boiled  molasses  are  given  to  children  for  lax- 
ative purposes,  and  are  very  effective.  A  suppository, 
having  been  first  oiled,  should  be  introduced  very  grad- 
ually and  gently  into  the  rectum,  the  patient  lying  on 


CKOPHAGU. 


The  alimentary  canal. 

the  left  side  as  for  an  enema.  It  should  pass  well  be- 
yond the  sphincter  ani,  and  it  is  well  to  keep  the  finger 
applied  for  a  moment,  until  the  rectum  becomes  accus- 
tomed to  its  presence,  to  lessen  the  danger  of  its  imme- 
diate expulsion.  Suppositories  containing  one  drachm 
of  glycerin  are  now  often  used  in  place  of  enemata. 


SUPPOSITORIES  109 

They  usually  produce  an  effect  within  fifteen  or  twenty 
minutes  by  setting  up  uniform  peristaltic  action  and 
increasing  the  secretion  from  the  intestinal  glands. 

The  nurse  is  often  called  upon  to  wash  out  a  pa- 
tient's stomach,  a  process  much  like  that  of  washing 
the  bladder,  already  described.  Either  a  regular  stom- 
ach-tube or  a  fountain  syringe  may  be  used.  In  the 
absence  of  either,  a  piece  of  rubber  tubing  attached  to 
a  funnel  will  serve  the  purpose.  Clean  the  apparatus 
thoroughly,  fill  the  bag  of  the  syringe  or  a  pitcher,  from 
which  to  pour,  with  lukewarm  water,  oil  the  tube,  and 
instruct  the  patient,  after  passing  it  well  back  in  the 
mouth,  to  swallow  slowly,  breathing  as  naturally  as  pos- 
sible. After  this  is  done,  the  bag  is  raised,  and  the 
contents  allowed  to  pass  slowly  into  the  stomach.  When 
it  is  full,  generally  retching  will  develop;  if  not,  when 
no  more  fluid  passes  into  the  tube,  it  should  be  de- 
tached from  the  bag,  and  the  outer  end  placed  over  a 
basin  into  which  the  contents  of  the  stomach  may  drain 
out.  Eepeat  until  the  fluid  runs  clear;  then  remove 
the  tube  steadily  and  rapidly.  Usually  liquid  food  is 
given  after  the  washing. 

"  Whene'er  a  noble  deed  is  wrought, 
Whene'er  is  spoken  a  noble  thought, 
Our  hearts  in  glad  surprise 
To  higher  levels  rise. 

"  Honor  to  those  whose  words  and  deeds 
Thus  help  us  in  our  daily  needs, 
And  by  their  overflow 
Raise  us  from  what  is  low." 

Longfellow. 


CHAPTER   VIII 

"Nothing  has  such  power  to  broaden  the  mind  as  the  ability 
to  investigate  systematically  and  truly  all  that  comes  under  thy 
observation  in  life." — Marcus  Aurelius  Antoninus. 

A  GREAT  point  of  distinction  between  the  trained 
and  the  untrained  nurse  is,  or  should  be,  the  ability  of 
the  former  to  observe  accurately,  and  to  describe  intelli- 
gibly, what  comes  under  her  notice.  The  nurse  who  is 
with  her  patient  constantly,  has,  if  she  knows  how  to 
make  use  of  it,  a  much  better  opportunity  of  becoming 
acquainted  with  his  real  condition  than  the  physician, 
who  only  spends  half  an  hour  with  him  occasionally. 
The  very  excitement  of  his  visit  will  often  temporarily 
change  the  entire  aspect  of  the  patient,  and  make  him 
appear  better  or  worse  than  he  really  is.  In  order  to 
form  correct  judgments  it  is  necessary  for  the  physi- 
cian to  know  what  goes  on  in  his  absence,  as  well  as  in 
his  presence,  and  for  such  information  he  is  forced  to 
rely  almost  wholly  upon  the  nurse.  It  is  thus  of  the 
greatest  importance  that  she  cultivate  the  habit  of  criti- 
cal observation  and  simple,  direct,  truthful  statement. 
Even  where  there  is  no  intent  to  deceive,  very  few  peo- 
ple are  capable  of  making  a  report  of  anything  which 
shall  be  neither  deficient,  exaggerated,  nor  perverted. 
The  doctor  wants  facts,  not  opinions ;  and  a  nurse  who 
can  tell  him  exactly  what  has  happened,  without  ob- 
scuring it  in  a  cloud  of  vague  generalities,  hasty  infer- 
UO 


Ill 

ences,  or  second-hand  information,  will  be  recognized 
as  an  invaluable  assistant. 

The  phenomena  which  accompany  disease  are 
termed  symptoms.  ,  These  may  be  classified  as  subjec- 
tive, those  which  are  evident  only  to  the  patient;  ob- 
jective, which  may  be  appreciated  by  outside  observers ; 
and  simulated,  feigned  for  purposes  of  deceit,  either  to 
excite  sympathy,  or  from  other  motives.  It  requires 
both  experience  and  judgment  to  enable  one  to  distin- 
guish between  real  and  feigned  symptoms.  An  expert 
malingerer  will  now  and  then  deceive  an  entire  hospital 
staff  into  the  treatment  of  a  malady  that  has  no  real 
existence;  while,  on  the  other  hand,  genuine  suffering 
may  chance  to  be  mistaken  for  fraud,  or  hysteria,  if  tfye 
usual  objective  manifestations  are  absent.  The  diffi- 
culty of  determining  the  false  from  the  true  is  often 
very  great,  especially  where,  as  is  frequently  the  case, 
there  is  an  undoubted  basis  of  fact.  Entirely  subjective 
symptoms  may  always  be  regarded  with  some  degree  of 
suspicion,  as  disease  unaccompanied  by  any  outward 
sign  is  comparatively  rare.  It  is  better  to  be  duped 
once  in  a  while  than  to  fail  to  give  aid  or  sympathy 
where  it  is  really  needed;  but,  without  letting  the 
patient  feel  that  he  is  being  watched,  let  nothing  pass 
unseen,  note  the  most  fleeting  signs,  and,  if  you  have 
any  quickness  of  perception,  you  will  soon  get  an  im- 
pression of  his  mental  attitude  as  well  as  his  physical . 
state,  and  can  judge  to  some  extent  whether  his  state- 
ments are  to  be  relied  upon,  and  whether  he  has  a 
tendency  to  exaggerate  his  ills,  or  to  make  light  of 
them. 

To  decide  as  to  the  existence  of  disease,  of  course 
belongs  solely  to  the  doctor,  but  he  will  be  largely  guid- 
ed by  the  observations  of  the  attentive  nurse,  and  she 


A  TEXT-BOOK  OF  NURSING 

herself  will  often  be  called  upon  to  judge  as  to  the 
urgency  of  special  indications.  Shall  she  send  for  the 
doctor  in  the  middle  of  the  night,  or  apply  her  own 
resources?  shall  she  give  or  withhold  the  medicine  left 
to  be  used  only  in  emergency?  shall  she  alter  or  let 
alone  an  arrangement  which  has  proved  unexpectedly 
uncomfortable?  are  questions  constantly  arising.  The 
nurse  needs  to  be  able  to  discriminate  between  the  im- 
portant symptoms  and  those  which  are  merely  inci- 
dental— to  recognize  those  which  call  for  immediate 
action,  and  to  know  what  kind  of  action  on  her  part  is 
called  for. 

When  you  have  acquired  the  habit  of  observation  so 
nqcessary  for  you,  you  will,  at  the  first  glance  at  a  new 
patient,  get  an  idea  of  his  general  physiognomy  and  any 
prominent  peculiarities ;  closer  investigation  will  reveal 
more  minute  particulars. 

Try  to  learn  all  you  can  of  the  previous  history  of 
the  case ;  you  will  sometimes  get  valuable  points  which 
the  patient  would  hesitate,  or  not  think  of  sufficient 
consequence,  to  mention  to  the  doctor  in  person. 

Note  the  patient's  apparent  age,  with  any  indica- 
tions of  premature  or  disguised  age,  signs  of  weakness, 
size,  whether  well  or  ill  nourished,  emaciated,  corpu- 
lent, or  bloated,  and  any  deformities,  swellings,  or 
wounds. 

Attitude  and  expression  are  sometimes  very  charac- 
teristic, giving  valuable  indications.  A  sufferer  in- 
stinctively takes  the  position  most  calculated  for  ease. 
Thus,  when  one  lung  is  affected,  the  patient  lies  on  that 
side,  so  that  the  healthy  one,  which  has  to  do  most  of 
the  work,  may  have  the  greatest  freedom  of  motion. 
Lying  on  the  back,  with  the  knees  drawn  up  so  as  to 
relax  the  abdominal  muscles,  suggests  peritonitis.  With 


THE   OBSERVATION  OF  SYMPTOMS  113 

colic,  on  the  contrary,  you  may  find  the  patient  lying 
on  the  abdomen,  as  pressure  relieves  pain  of  such  char- 
acter. When  a  patient  who  has  lain  persistently  on 
his  back  turns  over  to  the  side,  it  may  be  looked  upon 
as  a  sign  of  improvement.  There  is  no  surer  indication 
that  the  distress  of  dyspnoea  is  removed  than  for  a  pa- 
tient, who  has  been  forced  to  sit  up,  to  lie  down  and 
compose  for  sleep.  The  inability  to  breathe  while  lying 
down  is  termed  orthopncea.  It  occurs  in  affections  both 
of  the  lungs  and  of  the  heart.  Lying  quietly  is  usually 
a  favorable  sign;  but  in  acute  rheumatism  the  patient 
is  quiet  because  the  least  motion  causes  pain.  Again, 
extreme  weakness  may  render  it  too  great  an  exertion 
to  move.  Eestlessness  is  ominous  in  most  organic  dis- 
eases. Slipping  to  the  foot  of  the  bed  is  sometimes  a 
very  bad  sign.  ^ 

A  pinched  and  anxious  look  is  often  the  forerunner 
of  serious  mischief,  while  a  tranquil  expression  is  usu- 
ally of  favorable  import.  Sudden  lack  of  expression, 
apathy,  or  immobility  of  features  is  a  bad  symptom, 
excluding  cases  of  hysteria  and  mental  weakness.  In 
facial  paralysis,  expression  will  be  totally  absent  from 
half  the  face,  or  it  will  be  drawn  and  distorted — the 
healthy  side  being  the  one  thus  affected. 

Some  painful  abdominal  affections  are  accompanied 
by  a  sort  of  sardonic  smile — ristis  sardonicus — from 
contraction  of  the  muscles  of  the  mouth.  Any  such 
contortion  of  feature  is  noteworthy,  as  also  extreme 
thinness  or  swelling  of  the  lips,  and  excessive  action  of 
the  nares.  The  facial  expression  in  sepsis  is  very 
marked  and  characteristic,  although  difficult  to  de- 
scribe. 

The  most  important  indices  of  disease  are  the  pulse, 
respiration,  and  temperature,  sometimes  called  the 


114  A  TEXT-BOOK  OP  NURSING 

three  vital  signs.  They  have  already  been  discussed 
under  their  several  heads.  The  three  are  intimately 
associated,  and  correspondingly  affected.  The  fre- 
quency, rhythm,  and  force  of  the  pulse  are  to  be  care- 
fully observed,  and  its  relations  to  other  symptoms. 
Note  the  rate  and  any  peculiarities  of  respiration, 
whether  it  is  most  abdominal  or  thoracic,  if  regular 
or  irregular,  easy  or  labored,  and  whether  or  not  ac- 
companied by  pain.  There  is  no  pain  in  disease  of 
lung-substance  alone;  when  the  pleura  is  involved, 
there  is  sharp  pain.  In  bronchitis  or  asthma  there  is 
difficulty  in  breathing,  an  evident  muscular  effort;  in 
pneumonia  it  is  rapid,  and  more  shallow  than  in  the 
former.  Dyspnoea  is  common  from  various  causes. 
There  is  one  very  peculiar  form  of  it,  known  as  the 
Cheyne-Stokes  respiration,  in  which  the  inspirations, 
at  first  short  and  shallow,  become  by  degrees  deep  and 
difficult  up  to  a  certain  point,  and  then  again  more  and 
more  superficial  until  they  entirely  cease.  After  a 
pause  of  from  a  quarter  to  half  a  minute,  the  same 
series  of  phenomena  are  repeated  in  the  same  order. 
This  is  a  curious  and  generally  a  fatal  symptom. 

Cautious  respiration  indicates  lung  trouble  of  some 
kind.  (Edema  of  the  lungs,  or  the  presence  of  fluid  in 
the  air-passages,  is  evidenced  by  rattling  and  shortness 
of  breath.  The  sounds  produced  by  the  passage  of  air 
through  the  fluid  in  the  air-cells,  bronchi,  or  cavities 
are  known  as  rales. 

Most  disorders  of  the  respiratory  organs  are  accom- 
panied by  cough.  This  is  caused  by  irritation  of  the 
air-passages,  and  is  often  an  effort  at  the  expulsion  of  a 
foreign  body.  Matters  coughed  up  are  called  sputa. 
Cough  not  accompanied  by  expectoration  is  said  to  be 
dry.  The  character  of  the  expectoration  varies  with 


THE  OBSERVATION  OP  SYMPTOMS  115 

different  diseases.  In  bronchitis  it  is  at  first  simply 
mucous,  later  it  may  become  purulent ;  in  chronic  cases 
it  is  thick  and  yellow.  The  sputa  of  phthisis  are  at  first 
tenacious  and  ropy,  sometimes  frothy,  at  an  advanced 
stage  becoming  purulent  and  streaked  with  blood; 
sometimes  peculiar  cheesy  lumps  are  expectorated.  In 
pneumonia  the  expectoration  is  for  the  most  part 
scanty;  after  a  certain  stage  it  has  a  characteristic  rust 
color,  and  a  tenacious,  tough  quality.  Gangrene  of  the 
lung  gives  dark,  greenish  sputa,  very  copious  and  offen- 
sive. Cancer  of  the  lung  has  a  peculiar  gelatinous  form 
of  expectoration.  In  children,  the  sputa  are  often  swal- 
lowed; if  thrown  up  mixed  with  food,  they  may  be 
known  to  come  from  the  stomach. 

Note  whether  mucus  accumulates  during  the  night, 
and  the  time  of  day  when  the  cough  is  the  worst ;  if  it 
is  increased  by  moving,  or  on  first  waking;  the  charac- 
ter of  the  cough,  whether  hard  or  loose,  choking,  short, 
incessant,  or  paroxysmal.  Note  frequency,  duration, 
and  intensity  of  paroxysms,  and  if  followed  by  exhaus- 
tion or  perspiration.  The  brazen  ring  of  whooping- 
cough  is  well  known  and  unmistakable.  In  laryngismus 
stridulus,  "false  croup,"  a  spasmodic  affection  of  the 
glottis,  there  is  a  peculiar  crowing  sound.  Hoarseness, 
or  failure  of  the  voice,  known  as  aphonia,  may  arise 
from  disorder  of  the  respiratory  tract,  or  may  be  of 
purely  nervous  origin.  Singultus  or  hiccough,  a  spas- 
modic contraction  of  the  diaphragm,  ordinarily  of  small 
account,  is  an  important  and  unfavorable  symptom  to- 
ward the  close  of  an  acute  disease;  a  peculiarly  obsti- 
nate form  is  occasionally  seen  in  hysteria.  Yawning, 
sighing,  and  sneezing,  are  sometimes  noteworthy  as 
sympathetic  phenomena. 

If  a  patient  complains  of  cold  without  apparent  rea- 


116  A  TEXT-BOOK  OP  NURSING 

son,  take  his  temperature.  A  sense  of  coldness  along 
the  spine  is  ofter  the  precursor  of  a  chill,  and  the  tem- 
perature will  be  found  elevated  rather  than  lowered. 
Chills,  or  rigors,  are  nervous  phenomena ;  although  the 
patient  is  shivering,  the  temperature  rises,  because  the 
capillaries  are  so  much  contracted  that  the  blood  can 
not  get  to  the  surface  to  be  cooled.  High  fever  always 
follows  a  genuine  chill.  Chills  may  usher  in  acute  dis- 
ease ;  if  they  occur  in  the  course  of  inflammation,  they 
probably  indicate  suppuration;  in  malarial  affections 
they  are  severe  and  prolonged,  but  not  dangerous.  The 
temperature  should  be  taken  both  during  and  soon  after 
a  chill — the  time  of  occurrence,  duration,  number,  and 
degree  of  severity  should  all  be  carefully  noted. 

With  a  fall  of  febrile  temperature  there  is  apt  to 
be  profuse  perspiration.  Extreme  weakness,  and  other 
causes,  often  produce  the  same  result.  The  degree  of 
moisture  or  dryness  of  the  skin  is  always  an  important 
point.  A  high  temperature  with  a  wet  skin  is  much 
more  alarming  than  the  same  temperature  with  a  dry 
skin.  Note  in  what  part  of  the  body  moisture  appears, 
at  what  time,  in  connection  with  what  other  symptoms, 
whether  it  is  cold  or  warm,  and  if  there  is  any  peculiar 
odor  about  it. 

The  skin  affords  other  conspicuous  signs  as  well. 
Variations  from  a^ealthy  color  will  at  once  attract  at- 
tention. The  yellow  tinge  of  jaundice  is  well  known, 
indicating  disordered  action  of  the  liver.  A  bronze  hue 
is  present  in  Addison's  disease  and  in  some  cases  of 
septicaemia.  With  anaemia  there  is  a  peculiar  paleness ; 
in  Bright's  disease  a  waxy  complexion.  Chronic  opium- 
eaters  may  often  be  recognized  by  their  sallow  skin, 
taken  in  connection  with  other  appearances. 

A  red  color  shows  excess  or  suffusion  of  blood,  and 


THE  OBSERVATION  OF  SYMPTOMS  117 

a  cyanosed  or  bluish  shade,  imperfect  purification.  In 
pulmonary  disease  there  is  often  high  color  of  one  cheek 
alone.  Sudden  change  of  color  may  give  warning  of 
syncope.  Extreme  pallor  accompanies  internal  hemor- 
rhage. Paleness  about  the  mouth,  with  compressed  or 
slightly  parted  lips,  indicates  nausea.  Patches  of  color, 
flushing,  dark  circles  under  the  eyes,  have  each  their 
significance.  Any  eruption  or  rash  must  be  especially 
noticed  and  promptly  reported,  its  character,  location, 
extent,  time  of  appearance,  and  associated  symptoms. 
Of  less  consequence,  but  still  to  be  taken  into  account, 
are  deformities,  scars,  parasites,  the  cleanliness  of  the 
body,  any  roughness  of  the  skin,  etc.  Scaling  off  of  the 
cuticle  is  called  desquamation.  This  takes  place  gener- 
ally in  the  course  of  measles,  scarlet  fever,  and  some 
other  diseases.  Attention  will  probably  be  called  to  any 
local  irritation,  or  unnatural  sensation,  as  burning, 
tingling,  itching,  numbness,  or  crawling.  Early  signs 
of  bed-sores  can  not  be  too  carefully  watched  for.  The 
condition  of  wounds  must  receive  attention;  blushing 
or  puffiness  of  the  surrounding  parts,  sudden  stoppage 
or  alteration  in  the  quality  of  the  discharge,  should  be 
reported  at  once. 

The  eye,  besides  its  own  local  affections,  may  give 
signs  of  general  disorder.  It  may  appear  unduly  promi- 
nent or  sunken,  there  may  be  altered  color  or  inflamma- 
tion of  the  conjunctiva,  disturbances  or  loss  of  vision. 
Observe  the  size  of  the  pupils,  if  one  or  both  are  con- 
tracted or  dilated.  Squinting,  if  habitual,  is  of  no  im- 
portance ;  but  if  it  comes  on  in  the  course  of  brain  dis- 
ease, it  is  an  unfavorable  symptom.  Note  any  swelling 
of  the  eyelids,  drooping  or  tremulous  movement  of 
them,  fear  of  light,  apparent  weakness,  and  over-secre- 
tion of  tears. 
9 


118  A  TEXT-BOOK  OF  NURSING 

The  sense  of  hearing  may  be  preternaturally  acute, 
or,  more  commonly  and  less  significantly,  defective. 
The  former  condition  sometimes  precedes  delirium. 
Subjective  disturbances  of  hearing  may  arise  from  con- 
gestion of  the  cerebral  blood-vessels.  Some  drugs, 
notably  quinine,  produce  this  effect.  Any  discharge 
from  the  ear  should  be  noted  as  to  its  character  and 
amount. 

Taste,  like  the  other  special  senses,  may  be  impaired 
or  vitiated.  With  a  disordered  liver  there  is  often  a 
bitter  taste;  in  phthisis,  one  of  salt;  and  under  some 
medicinal  treatment  (mercury,  arsenic)  a  decided  me- 
tallic flavor.  The  sense  may  be  entirely  destroyed  for 
the  time;  it  is  rarely  over-acute. 

The!  tongue  offers  many  valuable  indications,  for  it 
sympathizes  not  only  with  the  digestive  organs,  but  to 
some  extent  with  the  whole  system.  Note  if  it  is  dry 
or  moist,  clean  or  coated,  swollen,  bitten,  or  indented 
by  the  teeth.  In  fever  the  tongue  is  likely  to  be  furred ; 
but  this  is  not  always  a  sign  of  disease,  for  some  people 
in  good  health  have  a  furred  tongue  constantly,  or  it 
is  induced  by  slight  constipation.  The  fur  may  be 
whi{e,  yellow,  or  any  shade  of  brown  to  nearly  black. 
When  the  fur  begins  to  grow  thin,  and  clean  up  from 
the  edges  of  a  fevered  tongue,  it  is  a  better  indication 
of  convalescence  than  when  it  clears  in  patches,  or 
rapidly,  leaving  a  raw  or  glossy  surface.  In  scarlet 
fever  there  is  often  a  characteristic  appearance  known 
as  the  "  strawberry-tongue,"  a  bright  red  with  the  swol- 
len papillae  showing  prominently  through  the  fur.  So 
the  swollen  and  livid  tongue  of  typhus  is  sometimes  de- 
scribed as  a  "  mulberry-tongue." 

Take  the  opportunity,  in  looking  at  the  tongue,  to 
notice  also  the  odor  of  the  breath  and  the  state  of  the 


THE  OBSERVATION  OF  SYMPTOMS  119 

teeth  and  gums.  Looseness  of  the  teeth,  and  sore 
gums,  are  to  be  watched  for  while  giving  mercurials. 
Salivation,  or  ptyalism,  an  over-abundant  secretion  of 
saliva,  is  occasioned  by  some  other  drugs  as  well  as 
mercury,  and  sometimes  occurs  spontaneously.  At  the 
commencement  of  acute  disease  this  secretion  is  more 
likely  to  be  diminished  in-  quantity,  and  thickened. 
With  high  fever,  the  teeth,  if  not  well  cared  for,  may 
become  covered  with  an  accumulation  of  dark-brown 
matter  known  as  sordes.  A  dark  line  appearing  along 
the  edges  of  the  gums  is  a  thing  to  call  attention  to; 
it  is  an  evidence  of  lead-poisoning.  Aphthae  (thrush) 
are  to  be  looked  out  for  in  infants,  and  sometimes  occur 
also  in  adults  in  an  advanced  stage  of  disease.  White 
patches  in  the  throat  are  always  ominous.  Learn  to 
distinguish  the  discrete  white  spots  of  quinsy  from  the 
diffuse  grayish  membrane  of  diphtheria.  Slight  sore 
throat  not  infrequently  accompanies  indigestion,  or  a 
cold. 

The  state  of  the  appetite  is  an  important  point. 
Nearly  all  acute  diseases  occasion  loss  of  appetite.  An 
increased  appetite,  bulimia,  is  more  rare,  but  may  exist 
even  with  an  inability  to  retain  food.  The  appetite 
may  be  vitiated,  the  patient  desiring  improper  food; 
but,  as  a  rule,  a  longing  for  particular  things  shows  a 
need  of  them  which  ought  to  be  gratified.  Observe 
with  special  care  how  much  food  the  patient  takes,  what 
kinds  of  food  are  most  acceptable,  and,  as  far  as  you 
can,  the  effects  of  each. 

Thirst  may  remain  when  the  appetite  is  completely 
lost.  It  almost  always  exists  in  acute,  seldom  in  chron- 
ic disease.  A  very  common  symptom  is  nausea.  It  is 
usually  relieved  by  vomiting.  Note  if  it  is  persistent, 
if  vomiting  is  accompanied  by  straining  or  pain,  the  in- 


120  A  TEXT-BOOK  OF  NURSING 

terval  since  taking  food  or  medicine,  the  amount  and 
character  of  the  vomited  matter.  This  will  be  gener- 
ally undigested  food ;  it  may  contain  bile,  blood,  or  even 
fascal  matter.  The  presence  of  the  latter  constitutes 
stercoraceous  vomiting,  and  is  a  very  important  symp- 
tom, as  it  indicates  intestinal  obstruction,  which  may 
call  for  immediate  operation.  An  appearance  like  that 
of  coffee-grounds  is  sometimes  caused  by  the  admixture 
of  a  small  quantity  of  blood.  The  "  black-vomit "  of 
yellow  fever  has  something  of  this  character.  When 
blood  is  present  to  any  extent  in  vomited  matter,  it  is 
usually  found  also  in  the  stools,  giving  them  a  dark 
color  and  tarry  consistency.  Some  drugs,  as  iron  and 
bismuth,  also  blacken  the  stools.  With  jaundice,  they 
will  be  very  light,  clay-colored.  It  is  important  to  note 
the  frequency  and  quantity  of  the  evacuations,  if  solid 
or  liquid,  any  unnatural  odor  or  appearance,  the  pres- 
ence of  mucus,  pus,  blood,  or  worms.  If  there  is  any 
doubt  about  the  character  of  stools  or  vomited  matter, 
they  should  be  saved  for  the  doctor's  inspection. 
Tenesmus — a  constant  desire  to  empty  the  bowel,  with 
pain  and  inability  to  do  so — is  a  distinguishing  symp- 
tom of  dysentery.  Constipation  is  very  common,  and 
is  often  produced  by  over-use  of  cathartics  or  clysters. 
Diarrho3a  may  exist  even  with  impacted  faeces,  the  pa- 
tient having  frequent  small  movements  without  unload- 
ing the  bowels.  What  is  passed  under  such  circum- 
stances will  be  either  fluid,  or  small,  dark,  hard  masses, 
known  as  scybala.  This  is  important  to  remember,  for 
a  nurse  is  too  apt  to  have  the  idea  that  the  patient's 
bowels  must  be  all  right  if  they  move  daily,  without 
regard  to  the  quantity  passed.  Where  a  stricture  exists, 
the  evacuations  will  be  very  small  in  caliber.  Eructa- 
tions of  gas,  rumblings  in  the  intestines,  and  tympani- 


THE  OBSERVATION  OF  SYMPTOMS  121 

tes  (distention  of  the  abdomen  by  gas),  are  all  note- 
worthy, as  also  dysuria  (painful  passage  of  urine),  and 
suppression,  retention,  or  incontinence.  The  latter  is 
no  evidence  that  the  bladder  is  empty.  There  are  many 
important  indications  to  be  derived  from  the  urine,  as 
has  already  been  mentioned.  In  case  of  dyspnoea  with- 
out apparent  cause,  examine  the  urine,  and  test  it  for 
albumin. 

In  women  the  menstrual  function  calls  for  special 
observation;  the  regularity  in  the  appearance  of  the 
catamenia,  whether  accompanied,  preceded,  or  followed 
by  pain,  and  any  related  phenomena. 

Haemorrhage  from  any  organ  is  always  more  or  less 
important.  Even  a  nose-bleed  may  be  an  initial  symp- 
tom of  typhoid.  The  color,  quantity,  and  general  char- 
acter of  any  discharge  are  to  be  carefully  observed. 

Pain  is  always  a  subjective  symptom,  though  most 
often  accompanied  by  others  which  are  objective.  Pain> 
implies  life  and  reaction,  and  its  absence  is  not  always 
a  favorable  indication.  With  an  extreme  degree  of 
shock  there  is  no  pain.  Sudden  cessation  of  pain  during 
the  progress  of  severe  organic  disease  generally  heralds 
the  approach  of  death.  Pain  may  be  inflammatory  or 
neuralgic ;  the  former  is  increased  by  pressure,  the  lat- 
ter relieved  by  it.  Get  the  patient  to  describe  the  kind 
of  pain  that  he  feels,  as  well  as  to  locate  it ;  to  tell 
whether  it  is  acute,  dull,  aching,  stinging,  burning, 
steady,  spasmodic,  etc.  Exaggerated  sensibility  is 
called  hyperaBsthesia ;  diminished  or  lost  sensibility, 
anaesthesia.  Either  may  be  general  or  local.  Partial 
anaesthesia  is  often  conjoined  with  loss  of  muscular 
power — paralysis.  If  the  lower  half  of  the  body  is  so 
affected,  it  is  called  paraplegia ;  paralysis  of  the  lateral 
half  is  hemiplegia.  In  hemiplegia  the  temperature 


122  A  TEXT-BOOK  OP  NURSING 

may  be  found  a  degree,  or  a  degree  and  a  half,  higher 
on  the  paralyzed  side  than  on  the  other.  Aphasia,  loss 
of  the  power  of  speech,  occurs  most  often  in  connection 
with  right  hemiplegia. 

Incoherence  of  speech,  muttering,  slowness  of  com- 
prehension, loss  of  interest,  unusual  irritability  of  tem- 
per, difficulty  of  swallowing,  a  tendency  to  spill  food  or 
drop  things,  and  picking  at  the  bedclothes,  are  all 
symptoms  of  gravity.  Involuntary  muscular  contrac- 
tions vary  from  slight  spasms,  as  cramps,  to  severe  con- 
vulsions. Subsultus  (twitching  of  the  muscles),  and 
many  little  nervous  motions  may  be  so  classed.  Note  the 
frequency  and  persistency  of  movement,  whether  the 
convulsions  are  general,  or  are  confined  to  one  part  of 
the  body,  whether  or  not  the  patient  is  unconscious,  and 
if  the  attack  is  sudden,  and  the  mental  state  before  and 
after  it. 

Under  disorders  of  consciousness  are  included  all 
sorts  of  delusions  and  hallucinations,  delirium,  and 
stupor,  as  well  as  mental  depression  or  unusual  excita- 
bility. Note  the  kind  of  delirium,  if  quiet,  busy,  or 
maniacal ;  if  persistent,  or  only  occasional,  and  when  it 
is  most  violent.  Try  if  the  patient  can  be  roused  from 
stupor.  Complete  insensibility,  from  which  the  patient 
can  not  be  awakened,  is  known  as  coma.  Profound 
coma,  which  does  not  terminate  within  twenty-four 
hours,  may  be  regarded  as  almost  certainly  fatal.  Con- 
tinuous sleeplessness,  with  partial  unconsciousness,  con- 
stitutes coma-vigil,  also  an  almost  invariably  fatal 
symptom.  Insomnia  is  always  ominous  in  proportion 
to  its  duration.  It  is  important  to  note  how  much 
sleep  a  patient  gets,  at  what  time,  whether  it  is  quiet 
or  disturbed,  the  occurrence  of  dreams,  talking  in  sleep, 
etc.  A  patient  will  often  think  he  has  been  awake  all 


THE  OBSERVATION  OF  SYMPTOMS  123 

night,  when,  in  fact,  he  has  had  several  hours  of  sleep 
without  realizing  it.  The  nurse  should  be  able  to  state 
the  facts  accurately. 

The  degree  of  intensity  of  all  symptoms,  the  time 
and  order  of  appearance,  and  the  combinations,  are  to 
be  observed.  Often  a  symptom,  which  by  itself  would 
be  insignificant,  becomes  in  its  relations  with  others  of 
grave  import.  If  uncertain  whether  a  circumstance  is 
of  any  value  or  not,  still  make  note  of  it,  for  it  is  better 
to  report  to  the  physician  a  dozen  superfluous  items 
than  to  omit  one  of  importance.  Do  not  trust  too  much 
to  memory,  but  keep  a  little  memorandum  book  in 
which  to  note  facts  and  take  down  orders.  A  sheet  of 
foolscap  ruled,  after  the  plan  shown  on  the  following 
page,  gives  a  good  form  for  bedside  notes. 

"  Look  up  and  not  down ; 
Look  out  and  not  in ; 
Look  forward  and  not  back, 
and  lend  a  hand." 

E.  E.  Hale. 


124 


DATE,- 


A  TEXT-BOOK  OF  NURSING 

BEDSIDE  NOTES 
DAY  OF  DISEASE, 


NAME. 


Time. 

Pulse. 

Res- 
pira- 
tion. 

Tem- 
pera- 
ture. 

Medicine.          Nourishment. 

Sleep. 

Urine. 

Defe- 
ca- 
tion. 

Remarks. 

Summary  : 

Nurse. 

CHAPTEE   IX 

"  Only  grant  my  soul  may  carry  high  through  death  her  cup 

unspilled,  .  .  . 
I  shall  boast  it  mine — the  balsam,  bless  each  kindly  wrench 

that  wrung 
Prom  life's  tree  its  inmost  virtue,   tapped   the  root  whence 

pleasure  sprung, 
Barked  the  bole  and  broke  the  bough  and  bruised  the  berry ; 

left  all  grace 
Ashes  in  death's  stern  alembic,  loosed  elixir  in  its  place." 

Robert  Browning. 

MATERIA  MEDICA  is  a  general  term  including  all 
remedial  agents.  An  official  list,  with  descriptions  of 
these,  and  instructions  for  their  preparation  and  use 
is  issued,  and  every  ten  years  revised,  by  a  national 
convention,  composed  of  delegates  from  various  medical 
societies.  This  publication  is  called  the  Pharmacopoeia. 
Such  medicaments  as  are  recognized  by  it  are  termed 
officinal.  The  composition  and  preparation  of  medicines 
is  pharmacy.  Drugs  have  been  classified  into  five 
groups : 

1.  Those  promoting  constructive  changes. 

2.  Those  promoting  destructive  changes. 

3.  Those  preventing  septic  decomposition. 

4.  Those  modifying  the  nervous  system. 

5.  Those  causing  some  evacuation. 

Some  have  a  purely  local  effect,  while  others  are 
more  general  in  their  action ;  some  have  a  special  affini- 
ty for  certain  organs,  while  yet  influencing  the  whole 

125 


126  A  TEXT-BOOK  OF  NURSING 

system.  Effects  may  be  primary  or  secondary,  direct 
or  remote.  The  action  of  any  drug  must  always  be 
preceded  by  its  absorption.  To  be  absorbed,  it  must 
be  in  solution,  or  of  such  a  nature  that  it  will  be 
changed  into  a  soluble  salt  within  the  body.  Many 
medicines  are  now  put  up  in  tablet  triturates,  a  neat, 
convenient,  and  compact  form.  The  drug,  having  been 
triturated  with  sugar  of  milk,  is  made  into  a  soluble 
paste  with  alcohol  and  water  in  varying  proportions, 
and  then  molded  into  uniform  tablets.  These  provide 
exact  dosage,  and  can  be  kept  indefinitely.  Similar 
tablets  are  also  made  for  hypodermic  use,  and  for  anti- 
septic solutions. 

A  saturated  solution  of  any  substance  is  one  that 
contains  all  that  can  be  dissolved  in  it. 

A  mixture  is  a  suspension  in  some  vehicle  of  an  in- 
soluble substance. 

An  emulsion  is  a  mixture  of  oil  and  water,  made  by 
rubbing  up  with  gum. 

A  decoction  is  a  solution  of  a  vegetable  substance 
made  by  boiling.  Decoctions,  as  a  rule,  do  not  keep 
well,  and  should  be  freshly  made  at  least  once  in  forty- 
eight  hours.  To  an  ounce  of  the  crude  drug,  add  fif- 
teen ounces  of  water,  and  boil  down  to  ten  ounces. 

An  infusion  is  a  similar  preparation  made  with  hot 
or  cold  water,  without  boiling.  One  ounce  of  the  drug 
to  ten  of  water  is  now  the  rule. 

Spirits  are  alcoholic  solutions  of  volatile  substances. 

Tinctures  are  alcoholic  solutions  of  non-volatile 
substances. 

Fluid  extracts  are  like  tinctures,  but  stronger. 

These  are  some  of  the  most  common  of  the  numer- 
ous pharmaceutical  preparations. 

Medicines    may    be    introduced    into    the    system 


MEDICINES  AND  THEIR  ADMINISTRATION    127 

through  the  skin,  the  mucous  membrane,  or  the  sub- 
cutaneous tissue,  with  the  same  constitutional  results, 
but  differing  in  degree,  and  in  the  time  required  to 
produce  them. 

There  are  three  ways  of  introducing  medicine 
through  the  skin,  known  respectively  as  the  enepider- 
mic,  the  epidermic,  and  the  endermic  methods.  In  the 
first,  the  medicinal  agent  is  simply  placed  in  contact 
with  the  skin,  to  be  absorbed,  so  far  as  may  be,  by  it. 
If  friction  is  employed  to  hasten  absorption,  the  method 
becomes  epidermic.  In  the  endermic  method  the  cu- 
ticle is  removed  by  blistering,  and  the  medicament 
sprinkled  over  the  raw  surface ;  absorption  is  then  much 
more  rapid.  This  is  now  but  rarely  practiced,  as, 
although  sometimes  effective,  it  is  painful  and  some- 
what uncertain. 

Endermic  medication  has  been  largely  superseded 
by  hypodermic  or  subcutaneous  injections.  These  the 
nurse  will  frequently  have  to  give,  and  she  must  be 
thoroughly  familiar  with  the  process.  There  are  sev- 
eral precautions  to  be  observed.  A  new  syringe  should 
be  compared  with  a  standard  minim-glass,  as  the  meas- 
urements vary  considerably,  and  accuracy  is  highly  im- 
portant. See  that  it  is  in  good  working  order,  does  not 
leak,  and  that  the  needle  is  sharp  and  unobstructed. 
Having  carefully  measured  the  amount  to  be  adminis- 
tered, hold  the  instrument  with  the  needle  upward,  and 
force  out  any  bubbles  of  air  that  may  remain  in  it.  Then 
pinch  up  a  loose  fold  of  flesh  between  the  thumb  and 
finger,  and  insert  the  needle  quickly  to  the  extent  of  an 
inch  deeply  down  among  the  muscles.  Withdraw  it 
slightly,  then  inject  slowly  the  contents  of  the  syringe. 
After  removing  the  needle,  keep  a  finger  on  the  point  of 
insertion  for  a  moment,  to  prevent  the  escape  of  the 


128  A   TEXT-BOOK  OP  NURSING 

fluid.  Gentle  rubbing  will  hasten  its  absorption.  Tab- 
lets for  use  in  the  hypodermic  syringe  are  put  directly 
into  the  barrel,  water  drawn  into  it  until  the  cylinder 
is  full,  and  after  well  shaking  to  dissolve  the  tablet, 
the  solution  is  ready  to  inject.  Clean  and  wipe  both 
needle  and  syringe  after  using,  and  replace  the  wire 
in  the  needle  at  once.  The  best  way  to  clean  the  inside 
is  to  pump  a  little  alcohol  through  it.  This  also  will 
prevent  the  needle  from  rusting.  Hypodermic  injec- 
tions are  given  to  relieve  pain,  or  induce  sleep,  and 
when  speedy  action  of  a  drug  is  important.  Kesults 
may  be  expected  in  about  five  minutes.  Eemedies  intro- 
duced in  this  way  act  more  powerfully  and  more  rap- 
idly than  in  any  other,  and  the  operation,  if  skillfully 
performed,  is  but  slightly  painful.  By  using  a  clean, 
aseptic  needle  and  giving  the  injection  deep  in  the 
muscle,  the  most  irritating  fluids  (ether,  brandy,  cam- 
phorated oil,  etc.)  can  be  injected  with  impunity.  Such 
injections  are  frequently  necessary  in  collapse  after 
operations.  The  liability  to  the  formation  of  abscess  is 
said  to  be  least  where  morphine  is  used.  Abscesses  are 
in  most  cases  due  either  to  carelessness  in  injecting,  to 
the  use  of  a  syringe  not  thoroughly  clean,  or  to  an  im- 
pure solution,  but  occasionally  are  unavoidable,  result- 
ing from  a  lowered  condition  of  the  system,  which  pre- 
disposes to  inflammation  upon  slight  irritation.  A 
dilute  is  less  irritating  than  a  concentrated  solution. 
In  some  cases  painful  spots  will  remain  for  several  days. 
These  may  be  relieved  by  bathing  with  alcohol,  or  by  the 
application  of  an  ice-bag.  Give  the  hypodermic  injec- 
tion in  the  arm  or  leg,  never  in  the  neck  or  stomach, 
though  you  may  occasionally  see  a  physician  do  it.  In 
treating  a  lady,  it  is  better  to  avoid  the  arm,  on  account 
of  the  possibility  of  a  resulting  abscess,  which  might 


MEDICINES  AND  THEIR  ADMINISTRATION     129 

leave  an  unsightly  scar.  The  outer  side  of  the  thigh  is 
perhaps  the  best  place.  The  distance  from  the  seat  of 
pain  makes  no  difference,  as  the  effect  is  systemic,  not 
local.  Bony  prominences  and  inflamed  parts  are  to  be 
avoided,  and  caution  observed  against  puncturing  a 
vein.  Death  has  resulted  from  the  introduction  of  a 
solution  of  morphia  directly  into  a  vein.  Intravenous 
injection  is  occasionally  practiced,  but  only  by  the  phy- 
sician, and  its  consideration,  except  as  a  thing  to  be 
avoided,  does  not  enter  into  the  province  of  a  nurse. 
Medicines  to  be  given  subcutaneously  must  be  perfectly 
dissolved,  and  free  from  the  slightest  impurity.  Solu- 
tions too  long  kept  develop  a  fungoid  growth,  which 
renders  them  unfit  for  hypodermic  use.  Decomposi- 
tion may  be  prevented  by  adding  ac.  salicyl.,  gr.  £,  to 
an  ounce  of  solution.  It  is  much  better  to  prepare 
them  only  as  needed.  To  the  solution  of  morphine,  a 
little  atropine  should  always  be  added  (gr.  1-120  to 
morph.  gr.  1-6),  to  prevent  nausea  and  lessen  the 
danger  of  poisoning.  In  hysterical  patients,  as  well 
as  in  those  accustomed  to  the  use  of  morphine  in  minor 
ailments,  a  hypodermic  injection  of  water  sometimes 
has  quite  as  satisfactory  an  effect. 

Some  general  effects,  as  well  as  those  locally  upon 
the  throat  and  lungs,  may  be  obtained  by  inhalation. 
In  this  way  anaesthesia  is  induced  by  chloroform,  ether, 
or  nitrous  oxide  gas.  This  is  a  rapid  method  owing 
to  the  abundant  blood  supply  in  the  lungs.  Volatile 
substances  to  be  inhaled  may  be  simply  evaporated 
from  a  piece  of  cloth  or  cotton  held  near  the  nostrils. 
Others  can  be  finely  subdivided  by  a  hand  or  steam 
atomizer  throwing  the  spray  into  the  mouth.  The  pa- 
tient should  be  directed  to  breathe  quietly,  without 
extra  effort.  A  simple  and  convenient  device  for  the 


130  A  TEXT-BOOK  OP  NURSING 

inhalation  of  steam,  or  medicinal  vapor,  is  a  pitcher  of 
hot  water,  having  closely  fitted  over  it  a  cone  of  thick 
paper,  with  an  aperture  at  the  top  through  which  the 
patient  may  breathe.  He  should  inhale  by  the  mouth, 
and  exhale  through  the  nose.  The  temperature  of  the 
vapor  should  not  exceed  150°  Fahrenheit.  It  is  made 
medicinal  by  the  addition  to  the  hot  water  of  prescribed 
drugs. 

The  most  common  mode  of  introducing  medicines 
into  the  system  is  through  the  mucous  membrane,  gen- 
erally that  of  the  stomach.  Applications  to  other  parts 
of  it  are  more  frequently  for  local  effect,  and  are 
spoken  of  elsewhere. 

Medicines  are  taken  into  the  stomach  in  various 
forms  of  pills,  powders,  and  solutions.  With  this  meth- 
od about  twenty  minutes  will  elapse  before  the  drug 
begins  its  action.  The  process  is  a  little  more  rapid 
if  given  on  an  empty  stomach.  Some  patients  find  an 
almost  insuperable  difficulty  in  taking  pills.  The 
smaller  the  pill,  the  harder  it  is  to  swallow,  but  if  its 
size  is  increased  by  enveloping  it  in  bread  or  jelly,  the 
trouble  will  often  be  overcome.  Place  it  as  far  back 
in  the  throat  as  possible,  and  follow  immediately  with  a 
large  swallow  of  water.  Pills  that  have  been  long  kept 
become  very  hard,  and,  if  taken  in  that  condition,  may 
pass  through  the  intestinal  canal  undissolved,  and  so 
without  effect.  If  nothing  better  can  be  procured,  they 
should  be  pounded  up,  and  given  like  powders,  in  water, 
milk,  or  sirup.  A  small  powder  may  be  concealed  be- 
tween two  layers  of  jam  or  marmalade,  and  swallowed 
without  difficulty.  Powders  insoluble  in  water,  as  calo- 
mel or  bismuth,  may  be  placed  dry  on  the  tongue,  and 
a  drink  taken  to  wash  them  down.  Those  of  objec- 
tionable flavor  are  frequently  inclosed  in  wafers  of  rice- 


MEDICINES  AND  THEIR  ADMINISTRATION    131 

paper,  or  in  capsules  of  gelatin,  either  of  which  will 
dissolve  and  liberate  its  contents  in  the  stomach.  Pre- 
sent pills  or  capsules  in  a  saucer  or  spoon,  not  from  the 
hand. 

If  there  are  no  special  orders  given,  allow  an  inter- 
val of  half  an  hour  between  medicine  and  food.  Most 
drugs  act  more  powerfully  on  an  empty  stomach,  and 
some  are  too  irritating  to  be  borne.  Arsenic,  iron,  and 
cod-liver  oil  are  always  given  after  eating.  If  medi- 
cines are  ordered  just  before  meals,  care  must  be  taken 
that  the  diet  is  not  such  as  to  be  incompatible.  Milk 
taken  too  near  a  dose  of  quinine  in  solution,  or  any 
acid,  may  be  coagulated  and  rejected.  The  activity  of 
iodine  will  be  impaired  by  starchy  food.  Inquire 
whether  the  medicine  should  be  diluted,  and  if  so,  to 
what  extent. 

The  spoon  or  glass  in  which  it  is  given  should  be 
washed  each  time  immediately  after  use.  Iron  and  the 
mineral  acids  should  be  taken  through  a  glass  tube,  to 
prevent  injury  to  the  teeth,  or  the  teeth  should  imme- 
diately after  be  thoroughly  brushed  with  a  soda  or 
borax  solution,  or  with  white  Castile  soap.  A  separate 
glass  should  be  kept  for  oily  and  strong-smelling  medi- 
cines. Disagreeable  tastes  may  be  to  some  extent  les- 
sened by  holding  the  nose  while  swallowing.  A  bit  of 
bread  is  better  than  anything  else  to  remove  lingering 
traces  of  the  flavor.  Licorice  and  dried  orange-peel,  or 
a  piece  of  preserved  ginger,  are  recommended,  but  bet- 
ter than  anything  to  take  after  medicine  is  some  pun- 
gent flavor  beforehand,  as  a  little  brandy,  essence  of 
peppermint,  or  wintergreen,  which  will  blunt  the  sensi- 
bility of  the  nerves  of  taste.  Oil  may  be  given  in 
brandy,  strong  coffee,  lemon-juice,  or  in  the  froth  of 
beer.  Pour  the  dose  carefully  in  the  center,  so  that  it 


132  A  TEXT-BOOK  OF  NURSING 

will  nowhere  touch  the  glass,  and  it  can  be  easily  swal- 
lowed. For  a  child,  shake  it  in  a  bottle  with  hot  milk, 
sweeten,  and  flavor  with  cinnamon,  or  stir  it  into  a 
cup  of  hot  broth.  Nearly  tasteless  emulsions  can  be 
procured  of  both  castor  and  cod-liver  oil. 

It  sometimes  becomes  necessary  in  the  case  of  a 
child  or  a  delirious  person  to  administer  medicine  by 
force.  To  do  this,  compress  the  nostrils  so  that  the 
mouth  will  have  to  be  opened  in  breathing.  The  medi- 
cine can  then  be  carried  in  a  spoon  far  back  in  the 
mouth,  and  poured  slowly  down  the  throat,  where  if 
not  swallowed,  it  will  be  slowly  absorbed.  Of  course 
only  fluids  can  be  given  in  this  way.  Powders  must 
never  be  given  to  an  unconscious  patient,  as  there  is 
danger  of  suffocation.  Force  should  only  be  resorted 
to  when  all  other  means  fail,  as  the  excitement  which 
it  occasions  is  always  injurious.  Persuasion  accom- 
plishes much  with  children,  and  even  an  apparently 
insensible  patient  may  often  be  induced  to  swallow  if 
you  first  attract  his  attention  by  gently  rubbing  the  lips 
with  the  spoon. 

Children  are  peculiarly  sensitive  to  the  action  of 
drugs,  and  usually  call  for  but  small  quantities.  A  rule 
given  for  the  administration  of  medicine  to  a  child 
under  twelve  years  is:  Add  12  to  the  child's  age  and 
divide  the  age  by  the  sum.  For  instance,  if  the  child 

2  21 

is  two  years  old,  the  formula  is  =  —  or  -  .     Give 

14:  7 


/>  n 

•$•  of  the  adult  dose.    If  the  child  is  six,  =  —  or 

O-J-1.C  lo 

-.    Give  i  of  the  adult  dose.    There  are  some  excep- 

8 

tions  to  this  rule,  as  calomel  and  castor-oil,  which  need 
only  be  reduced  about  one  half  for  a  child. 


MEDICINES  AND  THEIR  ADMINISTRATION    133 

The  nurse's  responsibility  in  the  matter  of  medi- 
cines consists  in  the  prompt,  accurate,  and  intelligent 
administration  of  such  as  are  prescribed  by  the  physi- 
cian. Only  in  cases  of  unusual  emergency,  and  where 
medical  advice  is  unattainable,  should  you  ever  assume 
anything  beyond  this.  You  will  be  frequently  asked 
to  recommend  something  for  this  or  that  trouble.  Do 
not  permit  yourself  to  yield  to  the  temptation  to  tell 
what  you  have  seen  used  in  similar  cases,  for  you  can 
not  be  sure  that  the  cases  were  exactly  similar.  Re- 
member that  a  well-disciplined  nurse  never  makes  a 
diagnosis,  and  never  prescribes.  But  you  should  know 
the  effect  that  the  remedies  which  you  give  are  intend- 
ed to  produce,  and  when  their  continuation  is  contra- 
indicated.  It  is  well  to  familiarize  yourself  with  the 
ordinary  doses  of  medicines  in  common  use,  and  with 
the  symptoms  of  overdosing. 

The  susceptibility  to  the  action  of  drugs  varies  in 
different  individuals,  and  is  much  modified  by  habit. 
This  is  especially  true  of  narcotics.  Custom  produces 
tolerance  and  diminished  impressibility,  so  that  after  a 
time  increased  quantities  are  required  to  produce  the 
same  effect.  There  is  great  danger  of  becoming  de- 
pendent upon  their  use.  The  habit — pre-eminently 
that  of  opium — is  so  easily  acquired,  so  difficult  to 
overcome,  and  is  followed  by  such  a  train  of  disastrous 
consequences,  that  the  greatest  care  should  be  taken 
to  avoid  it.  Narcotics  ought  never  to  be  used  except 
under  the  direction  of  a  physician.  After  giving  a 
narcotic,  the  patient  should  be  kept  as  quiet  as  possible 
until  it  takes  effect. 

If  a  medicine  ordered  in  gradually  increasing  doses 
is  for  a  time  discontinued,  the  acquired  tolerance  may 
be  lost,  and  upon  recommencing,  there  must  be  a  re- 
10 


134  A  TEXT-BOOK  OP  NURSING 

turn  to  the  smallest  dose,  or  too  powerful  effects  may 
follow. 

Some  drugs,  notably  digitalis,  have,  on  the  con- 
trary, a  cumulative  action,  seeming  at  first  inert,  but 
after  a  few  doses  acting  suddenly  and  with  great  energy, 
having  apparently  the  effect  of  the  several  doses  com- 
bined. Such  are  given  in  gradually  decreasing,  rather 
than  increasing,  doses. 

The  exact  results  of  a  given  dose  can  not  always  be 
foreseen.  It  occasionally  happens  that  individual  idio- 
syncrasies interfere  with  the  action  of  medicinal  agents, 
and  even  render  injurious  those  usually  salutary.  Thus 
opium  sometimes  excites  instead  of  quieting,  and  the 
smallest  quantity  of  mercury  will  salivate  a  susceptible 
constitution.  Strong  solutions  of  the  bichloride  should 
never  be  injected  into  any  of  the  mucous  tracts.  Every 
unusual  or  inordinate  action  of  a  drug  should  be  re- 
ported to  the  physician,  and  its  use  suspended  until 
further  directions  are  received.  If  a  dose  given  either 
by  stomach  or  rectum  is  rejected  within  five  minutes, 
it  may  be  once  repeated  after  an  interval  of  twenty 
minutes. 

Peculiar  effects  sometimes  depend  upon  the  imagi- 
nation, for  which  reason  it  is  better  that  the  patient 
should  not  always  know  what  he  is  taking.  His  medi- 
cine should  be  brought  to  him  at  the  proper  time,  ready 
to  take,  without  thought  on  his  part,  or  previous  dis- 
cussion. Regularity  and  promptness  in  its  adminis- 
tration are  important.  Do  not  fancy  that  half  an  hour 
more  or  less  will  make  no  difference,  nor  harbor  the  ab- 
surd notion  that  if  by  an  accident  the  dose  should  be 
omitted  at  one  hour  the  error  can  be  rectified  by  doub- 
ling it  the  next  time. 

Medicines  should  be  kept  in  a  dry,  cool,  and  dark 


MEDICINES  AND  THEIR  ADMINISTRATION    135 

closet.  Dampness  impairs  the  activity  of  most  drugs, 
and  many  are  decomposed  by  light  or  heat.  Only  a 
few  should  be  kept  on  hand,  each  in  small  quantity — as 
they  do  not,  as  a  rule,  keep  well — and  of  the  best  qual- 
ity. It  is  poor  economy  to  buy  drugs  where  they  are 
the  cheapest,  as  they  are  almost  sure  to  be  adulterated. 
Get  them  from  a  reliable  apothecary.  What  is  left  of  a 
prescription  the  use  of  which  is  permanently  discon- 
tinued should  be  thrown  away,  as  it  is  highly  improb- 
able that  the  same  combination  will  ever  be  called  for 
again,  and  most  of  them  undergo  changes  in  character 
by  age,  so  that  to  keep  them  only  increases  the  contents 
of  the  medicine-chest,  and  increases  the  liability  to 
error.  Liniments,  and  all  preparations  for  external 
use,  should  be  kept  in  a  corner  by  themselves,  and 
labeled  Poison.  Medicines  ought  to  be  kept  under  lock 
and  key.  Especially  is  it  important  in  a  hospital  ward 
not  to  leave  dangerous  drugs  within  reach  of  the  pa- 
tients. The  ward  medicine-chest  should  be  systemat- 
ically arranged,  each  bottle  or  box  in  its  own  place,  so 
that  there  need  be  no  delay  in  finding  things  called  for. 
All  bottles  should  be  distinctly  labeled,  and  one 
should  never  omit  to  carefully  read  the  label  before 
measuring  the  dose,  and  again  afterward.  Attention 
to  this  rule  would  have  prevented  many  serious  mis- 
takes. In  pouring,  keep  the  label  on  the  upper  side,  to 
avoid  defacing  it.  Remedies  for  external  use  are  now 
often  put  up  in  fluted  bottles  of  colored  glass,  recog- 
nizable to  touch  as  well  as  sight.  For  the  same  pur- 
pose, it  is  recommended  to  tie  a  bow  of  ribbon  around 
the  necks  of  the  bottles  containing  them.  No  medicine 
should  ever  be  given  in  the  dark.  Always  shake  before 
opening  the  bottle;  it  is  often  important,  and  always 
harmless.  Do  not  leave  the  bottle  uncorked  longer 


136  A  TEXT-BOOK  OP  NURSING 

than  necessary,  for  volatile  substances  escape,  and  oth- 
ers grow  more  concentrated  by  evaporation. 

Medicines  should  be  measured  in  a  graduated  glass, 
or  doses  of  less  than  a  drachm  in  a  minim-tube,  both  of 
which  can  be  procured  at  any  drug-store.  Spoons  are 
of  very  variable  capacity,  and  drops  differ  with  the  con- 
sistence of  the  fluid  and  the  shape  of  the  edge  over 
which  they  are  poured,  so  that  they  can  be  with  the 
greatest  care  only  approximately  measured.  A  minim, 
the  smallest  accurate  liquid  measure,  is  equivalent  to 
about  one  drop  of  an  aqueous  solution,  but  it  makes 
three  or  four  of  chloroform.  The  minim  of  any  tinc- 
ture is  usually  two  drops,  of  a  fluid  extract  but  one. 

APOTHECABIES'   MEASURES  FLUID   MEASURES 

gr.  xx  =  3j;  mix    =f3j; 

3iij    =3j;  f3viij  =  f§j; 

3viij  =lj;  f  |xvj  =   Oj; 

!xij   =B>j.  Oviij=   Cj. 

APPROXIMATE  MEASURES 

1  teaspoon  (holding  45  drops 

of  pure  water) =  about  3  j ; 

1  tablespoon "      "      §  ss ; 

1  wine-glass "      "      §  ij ; 

1  tea-cup "      "      §  iv ; 

1  coffee-cup "      "      §  viij. 

The  gramme  (gin.)  of  the  French  metric  system 
equals  about  15  grains.  The  cubic  centimetre  (c.  c.) 
equals  about  16  minims.  The  litre  equals  about  2  pints. 

The  gramme  is  the  unit  of  weight;  the  Latin  pre- 
fixes, deci,  centi,  milli,  etc.,  are  used  to  indicate  its  sub- 
divisions, and  the  Greek,  myria,  kilo,  hecto,  deka,  etc., 
its  multiples,  always  on  the  scale  of  ten.  In  place  of 


MEDICINES  AND  THEIR  ADMINISTRATION    137 


the  decimal  point,  a  vertical  line  is  sometimes  used,  at 
the  right  or  left  of  which  the  numbers  are  written,  as : 

myriagramme,  10,000 
kilogramme,    1,000 
hectogramme,       100 
dekagramme,        10 
gramme,  1 

decigramme,  1 

centigramme,  01 

milligramme,  001 

The  standard  weights  and  measures  should  be  thor- 
oughly familiar  to  every  nurse,  and  should  be  used  in 
place  of  the  ordinary  unreliable  measurements.  It  will 
be  found  an  advantage  to  have  also  a  ready  comprehen- 
sion of  the  symbols  and  abbreviations  used  in  writing 
prescriptions.  The  numbers  are  expressed  by  Roman 
figures,  and  follow  always  the  symbols  to  which  they 
relate,  as:  3j,  3jss.,  §ij,  gr.  iij,  3  iv,  gtt.  v,  Ib.  vj, 
Til  x,  etc. 


138 


A  TEXT-BOOK  OF   NURSING 


ABBREVIATIONS  AND  SYMBOLS 


AA,  ana,  of  each. 

Add.,  adde,  add  to  it. 

Ad  lib.,  ad  libitum,  as  you 
please. 

Alt.  hor.,  alternis  horis,  every 
other  hour. 

Alt.  noc.,  alter  a  node,  every 
other  night. 

Applic.,  applicatur,  apply. 

Aq.  dest.,  aqua  destillata,  dis- 
tilled water. 

Aq.  pur.,  aqua  pur  a,  pure  wa- 
ter. 

B.  i.  d.,  bis  in  dies,  twice  a  day. 

C.,  congius,  a  gallon. 

Cap.,  capiat,  let  him  take. 

Comp.,  compositus,  compound. 

Conf.,  confectio,  a  confection. 

Cort.,  cortex,  bark. 

Decub. ,  decubitus,  lying  down. 

Det.,  detur,  let  it  be  given. 

Dil.,  dilutus,  dilute. 

Div.  in  p.  aeq.,  dividatur  in 
paries  cequales,  divide  into 
equal  parts. 

Drachm.,  drachma,  a  drachm. 

Emp. ,  emplastrum,  a  plaster. 

PI.  or  f.,  fluidus,  fluid. 

Ft.,  fiat,  let  there  be  made. 

Garg. ,  gargarisma,  a  gargle. 

Gr.,  granum  or  grana,  a  grain, 
or  grains. 

Gtt.,  gutta  or  guttce,  a  drop,  or 
drops. 

Guttat.,  guttatim,  by  drops. 

Inf.,  infuaum,  an  infusion. 


Inject.,  injectio,  an  injection. 

Lb.,  libra,  a  pound. 

Liq.,  liquor. 

Lot.,  lotio,  a  lotion. 

M.,  misce,  mix. 

Mist.,  mistura,  a  mixture. 

N.,  node,  at  night. 

No.,  numero,  in  number. 

0.,  odarius,  a  pint. 

01.,  oleum,  oil. 

Ov.,  ovum,  an  egg. 

Pil.,  pilula,  a  pill. 

P.  r.  n.,  pro  re  nata,  as  occasion 

arises. 

Pulv.,  pulvis,  a  powder. 
Q.  S.,  quantum  sufficit,  as  much 

as  is  sufficient. 
5,  recipe,  take. 
Rad.,  radix,  root. 
S.  or  Sig.,  signa,  write. 
Sem.,  semen,  seed. 
SS.  or  s.,  semissis,  a  half. 
S.  V.  G.,  spiritus  vini  gallici, 

brandy. 
S.  V.  R.,  spiritus  vini  rectifi- 

catus,  alcohol. 
Syr.,  syrupus,  sirup. 
T.  i.  d.,  ter  in  dies,  three  times 

a  day. 

Tr.,  tinctura,  tincture. 
Troch.,  trochisci,  lozenges. 
Ung.,  unguenium,  ointment. 
Ul,  minimum,  a  minim. 
3  ,  drachma,  a  dram. 
§  ,  unica,  an  ounce. 
3,  scrupulum,  a  scruple. 


MEDICINES  AND  THEIR  ADMINISTRATION    139 


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A  TEXT-BOOK  OP  NURSING 


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ANTIKAMNI 

ANTIMONY. 

Tartar  ei 
Wine  of. 

ANTIPYRIN. 

A  POMORPH] 

ARISTOL. 

ARSENIC. 
Fowler's 

MEDICINES  AND  THEIR  ADMINISTRATION 


T-t     CO  •—  ' 

<H  ffi  h 

0 

g<     l  <M     t      ll 

a 

sed  in  nervous  complaints,  an< 
some  forms  of  dyspepsia.  Impart 
a  strongly  alliaceous  odor  to  al 
the  secretions, 
ctive  principle  of  belladonna. 

he  physiological  antagonist  o 
opium.  Used  externally  in  th 
form  of  a  liniment,  unguent,  o 
plaster. 

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MEDICINES  AND  THEIR  ADMINISTRATION    147 


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MEDICINES  AND  THEIR  ADMINISTRATION    151 


Niter,  Saltpeter. 
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Contains  two  per  cent  of  the  strong 
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Tartrate  of  Potash  and  Soda. 

The  blue  paper  contains  Rochelle 
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white,  tartaric  acid.  Dissolve 
each  separately,  and  pour  the 
larger  into  the  smaller.  Brisk 
effervescence  should  ensue.  Lem- 
on juice  and  sugar  will  improve 
the  taste.  The  powders  need  to 
be  kept  dry. 

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to  occasion  griping. 

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MEDICINES  AND  THEIR  ADMINISTRATION    153 


Acts  slowly.  Give  the  first  dose 
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WARBURG'S 

URE. 

o'^'S 

CHAPTER   X 

"  She  doeth  little  kindnesses 

Which  most  leave  undone  or  despise 
For  naught  that  sets  one  heart  at  ease, 
And  giveth  happiness  or  peace, 
Is  low  esteemed  in  her  eyes." 

J  B.  Lowell. 

BESIDES  general  remedies,  there  are  numerous  local 
or  topical  applications,  either  soothing,  irritant,  or 
protective.  Such  as  protect  by  arresting  fermentation 
are  called  antiseptic.  These  will  be  spoken  of  later. 

Poultices,  also  called  cataplasms,  are  in  common 
use  as  convenient  means  to  applying  warmth  and  moist- 
ure. Their  effect  is  to  soften  the  tissues  and  dilate  the 
capillaries,  relaxing  the  tension  of  inflamed  parts,  and 
so  relieving  pain.  Applied  early,  they  may  check  the 
progress  of  inflammation  and  prevent  the  formation  of 
pus;  when  suppuration  has  set  in,  they  facilitate  the 
passage  of  matter  to  the  surface  and  limit  the  spread 
of  inflammation.  They  are  useful  not  only  when  in  im- 
mediate contact  with  inflamed  tissues,  but  will  also 
often  relieve  deep-seated  pain.  A  poultice  applied  for 
the  relief  of  the  internal  organs,  or  to  hasten  matura- 
tion, ought  to  be  large  enough  to  extend  over  a  consid- 
erable surrounding  surface,  but  over  a  suppurating 
wound  should  be  but  little  larger  than  the  opening. 
Apply  as  hot  as  can  be  comfortably  borne,  but  do  not 
burn  the  patient.  There  is  danger  of  this  with  the  thin 
154 


POULTICES  155 

and  sensitive  skin  of  a  child,  and  in  cases  of  paralysis, 
when  the  generally  lowered  condition  gives  rise  to  an 
inability  to  resist  heat  and  cold,  and  the  skin  may  be 
blistered  by  a  poultice  that  would  produce  little  effect 
on  a  healthy  subject.  Cover  with  some  impervious  ma- 
terial— oiled  muslin  or  rubber  tissue — to  keep  in  the 
heat,  and  change  frequently,  the  exact  time  depending 
upon  the  thickness  of  the  poultice.  One  of  ordinary 
size  will  keep  warm  for  three  or  four  hours.  If  allowed 
to  become  cold  and  hard,  it  will  do  more  harm  than 
good.  Poulticing  should  not  be  too  long  continued,  or 
it  may  retard  rather  than  help  the  healthy  processes, 
by  rendering  the  flesh  sodden  and  irritable ;  it  may  even 
develop  an  eruption. 

Poultices  are  made  of  various  materials.  The  sim- 
plest form  consists  of  several  thicknesses  of  lint  or  soft 
cloth,  wrung  out  in  hot  water.  A  convenient  but  ex- 
pensive substitute  is  spongio-piline,  which  is  made  of 
two  or  three  layers  of  sponge  and  wool,  felted  together, 
and  coated  on  the  outer  surface  with  caoutchouc.  This 
holds  the  heat  a  long  time. 

Linseed  meal  is  very  generally  used,  and  when  of 
good  quality  is  an  excellent  material.  To  make  a  lin- 
seed poultice,  bring  a  saucepan  of  water  to  the  boiling- 
point,  and,  without  removing  it  from  the  fire,  stir  into 
it  the  meal  little  by  little,  until  it  has  the  proper  con- 
sistency— just  thick  enough  to  be  cut  with  a  knife.  It 
must  be  smooth  and  perfectly  free  from  lumps.  That 
eccentric  old  genius,  Dr.  Abernethy,  says  that,  if  it  is 
perfectly  worked  together,  you  might  throw  your  poul- 
tice up  to  the  ceiling,  and  it  would  come  down  without 
falling  in  pieces.  The  poultice  should  be  spread  evenly, 
about  a  quarter  of  an  inch  thick,  upon  a  piece  of  muslin 
previously  cut  to  the  desired  size,  leaving  an  inch  and 


156  A  TEXT-BOOK  OF  NURSING 

a  half  of  margin  in  each  direction.  Bartholow  advises 
that  the  muslin  be  twice  the  length  of  the  intended 
poultice,  only  half  of  it  spread,  and  the  remainder 
folded  back  as  a  cover,  but  it  is  rather  better  to  have 
a  separate  cover  of  some  thinner  material,  as  mosquito- 
netting,  old  tulle,  or  illusion,  if  such  can  be  obtained, 
and  to  fold  over  together  like  a  broad  hem  the  edges  of 
both.  This  makes  a  strong  border.  The  cover  is  some- 
times entirely  omitted,  and  the  poultice  applied  direct- 
ly to  the  skin,  but  portions  of  it  are  likely  to  adhere,  so 
that  it  becomes  difficult  to  remove  it  neatly.  A  little 
oil  on  the  poultice  will  help  to  keep  it  soft,  and  make  it 
less  likely  to  stick.  A  layer  of  cotton-wool  on  the  out- 
side will  help  to  retain  the  heat ;  and  when  the  weight 
of  a  poultice  is  painful,  and  it  has  in  consequence  to  be 
made  thin,  it  will  be  found  a  valuable  addition.  Some- 
times a  flannel  bag  is  made  to  contain  the  poultice,  one 
end  being  left  long  and  free  to  fold  over  it.  The  best 
way  to  apply  a  large  poultice  for  the  relief  of  the  inter- 
nal organs  is  to  make  one  or  two  turns  of  a  flannel 
bandage  about  the  part,  and  then  to  apply  the  poultice 
in  such  a  bag  and  confine  it  in  place  with  the  rest  of 
the  bandage.  So  arranged,  it  will  keep  hot  a  long 
time. 

A  small  board,  or  a  tray,  on  which  to  carry  the 
poultice  to  the  patient,  will  be  found  very  convenient, 
and  is  in  hospitals  always  used.  Quite  as  important  is 
it  to  have  a  basin  in  which  to  carry  away  the  old  one, 
which  should  always  be  burned.  If  it  is  to  be  applied 
to  a  wound,  the  old  poultice  will  have  been  removed, 
the  wound  washed,  and  protected  by  a  "guard" — a 
piece  of  muslin  wet  with  some  disinfecting  solution — 
before  the  fresh  one  is  made. 

A  poultice-jacket  is  sometimes  prescribed,  to  en- 


POULTICES  157 

velop  the  entire  chest.  This  is  made  in  two  pieces, 
front  and  back,  with  strings  to  tie  over  the  shoulders 
and  under  the  arms.  The  edges  must  be  firmly  sewed, 
to  keep  the  poultice  from  escaping. 

Bread  poultices  are  lighter  and  more  bland  than 
linseed,  but  cool  quickly  and  hold  less  moisture.  Not 
having  the  tenacious  quality  of  linseed,  they  are  likely 
to  crumble  and  become  rough  as  they  dry.  Milk  ought 
never  to  be  used  in  their  preparation,  as  it  has  no  ad- 
vantage over  water,  and  it  very  soon  becomes  sour  and 
offensive.  Pour  boiling  water  over  slices  of  bread 
without  crust.  Let  them  simmer  a  few  moments  until 
well  soaked,  then  drain  off  the  water,  beat  up  the 
bread  quickly  with  a  fork,  and  spread. 

As  bread  is  more  porous  than  linseed,  it  forms  a 
better  basis  for  the  charcoal  poultice.  The  formula 
given  is  :  Fresh  wood-charcoal  powder,  §  ss.;  bread 
crumbs,  ^rjj  linseed  meal,  §jss.;  boiling  water,  §x. 
Mix  half  the  charcoal  into  the  poultice,  and  sprinkle 
the  rest  either  over  its  surface  or  directly  upon  the 
wound.  This  poultice  needs  very  frequent  renewal.  It 
is  used  for  putrid  sores;  it  absorbs  the  fetid  odor  and 
promotes  a  healthy  condition,  but  it  is  always  a  dirty 
application,  and  other  neater  and  equally  effective  an- 
tiseptics have  largely  taken  its  place.  A  linseed  poul- 
tice may  be  made  with  some  disinfectant  solution 
instead  of  pure  water,  as  weak  carbolic  acid,  bichloride 
of  mercury,  or  solution  of  chlorinated  soda.  The  latter, 
as  well  as  correcting  the  odor,  affords  moderate  stimu- 
lation to  the  wound.  It  is  made  in  the  proportion  of 
one  part  Labarraque's  solution  to  four  of  water.  An- 
other gently  stimulant  application  is  the  yeast  poultice, 
mainly  used  to  hasten  the  separation  of  gangrenous 
sloughs.  Mix  six  ounces  of  yeast  with  the  same  quan- 


158  A  TEXT-BOOK  OF  NURSING 

tity  of  water  at  blood  heat;  stir  in  fourteen  ounces  of 
wheat  flour,  and  let  it  stand  near  the  fire  till  it  rises. 
Apply  while  fermenting.  Another  recipe  given  for  the 
yeast  poultice  is :  Mix  a  quarter  of  a  pound  of  flour,  or 
linseed  meal,  with  two  ounces  of  yeast  or  beer  grounds. 
The  mixture  is  then  heated,  being  constantly  stirred 
until  it  is  warm.  The  former  is  officinal.  Dough,  just 
as  mixed  for  bread,  will  answer  the  purpose  of  a  yeast 
poultice  admirably.  It  is  not  necessary  to  wait  for  it 
to  rise,  as  the  heat  of  the  body  will  cause  it  to  do  so. 
Put  a  sufficient  quantity  in  a  muslin  bag,  allowing 
plenty  of  room  for  it  to  rise. 

Starch  makes  a  very  bland  poultice,  and  retains  the 
heat  well.  It  is  used  for  cancers  and  to  allay  the  irrita- 
tion of  skin  diseases.  Make  as  for  laundry  use:  mix 
first  with  cold  water,  and  then  add  boiling  water  until 
it  thickens. 

Powdered  slippery  elm,  Indian  meal,  and  oatmeal 
are  also  used  for  poultices.  A  very  light  and  soothing 
one  may  be  made  of  one  part  slippery  elm  to  two  parts 
linseed  meal.  Scraped  carrots,  boiled  or  raw,  are 
thought  to  have  an  especially  cleansing  effect;  onions 
and  horse-radish  are  sometimes  used  for  their  stimula- 
ting properties.  A  hop  poultice  is  a  thin  bag  loosely 
filled  with  hops  and  wrung  out  in  hot  water.  This  has 
a  sedative  effect.  Bran  is  treated  in  the  same  way.  A 
bran  jacket  may  be  made  like  that  of  linseed,  above 
described,  and  has  the  advantage  that  the  same  one  can 
be  rewet  and  used  again  and  again.  It  needs  to  be 
stitched  through  and  through,  as  well  as  round  the 
edges,  to  keep  the  bran  in  place.  Bandage  close  to  the 
body  with  a  wide  roller. 

Laudanum  is  often  added  to  a  simple  poultice,  or 
sprinkled  over  its  surface,  for  the  relief  of  pain.  An- 


FOMENTATIONS  159 

other  sedative  poultice  sometimes  ordered  consists  of 
one  part  powdered  hemlock-leaf  to  three  parts  linseed 
meal.  In  either  case  the  constitutional  effects  of  the 
drug  are  to  be  looked  out  for. 

Camphor,  incorporated  in  a  bland  poultice,  is  some- 
times applied  to  the  perinaeum  for  the  relief  of  stran- 
gury. 

A  spice  poultice  is  made  by  mixing  ginger,  cinna- 
mon, clove,  and  Cayenne  pepper,  a  teaspoonful  of  each, 
with  half  an  ounce  of  flour,  and  brandy  enough  to  make 
a  paste.  The  same  effect,  that  of  mild  counter-irrita- 
tion, may  be  produced  by  sewing  the  spices  into  a  bag, 
to  be  dipped  into  whisky  or  brandy  when  required  for 
use. 

A  mustard  poultice  is  made  by  the  addition  to  a 
simple  linseed  poultice  of  a  prescribed  proportion  of 
mustard,  usually  from  one  eighth  to  one  fourth.  A 
good  substitute  for  a  mustard  poultice  may  be  made  by 
dipping  a  clean  flat  sponge  into  mustard  paste  prepared 
in  the  usual  manner.  Fold  this  in  a  handkerchief  or 
piece  of  muslin,  and  apply.  The  poultice  may  be  re- 
newed by  simply  moistening  the  sponge  afresh  with 
warm  water,  its  strength  being  perfectly  preserved. 

Fomentations  are  poultices  in  modified  form,  appli- 
cations of  hot  water,  pure  or  medicated,  by  means  of 
pieces  of  flannel  or  flat  sponges.  They  have  the  advan- 
tages of  being  clean,  light,  and  quickly  prepared;  but 
they  require  constant  attention,  needing  to  be  changed 
every  ten  or  fifteen  minutes.  Two  pieces  of  flannel 
should  be  at  hand,  each  doubled  to  the  desired  size. 
These  are  called  stupes.  They  are  to  be  saturated  with 
boiling  water,  and  wrung  out  as  dry  as  possible.  For 
this  purpose  a  stupe-wringer  is  needed — a  piece  of 
stout  toweling  with  a  stick  run  through  the  hem  at  each 


160  A  TEXT-BOOK  OF  NURSING 

end.  Put  the  stupe  in  the  middle  of  this,  saturate  with 
boiling  water,  and  twist  the  sticks  in  opposite  directions 
until  no  more  water  can  be  squeezed  out.  A  towel  may 
be  used  as  a  wringer,  but  there  is  danger  of  scalding 
one's  fingers.  A  stupe  cool  enough  to  be  wrung  out  by 
hand  is  too  cool  to  be  of  much  use.  It  should  be  dry 
enough  not  to  wet  the  bed  or  the  clothing.  Have 
another  all  ready  to  apply  before  removing  the  first. 
There  should  be  two  layers,  no  more.  Shake  these 
slightly  apart  to  let  the  air  in  between  them,  and  they 
will  keep  hot  longer.  Cover  with  oiled  muslin,  an  inch 
larger  in  each  direction  than  the  stupe,  and  over  that 
lay  a  piece  of  dry  flannel,  or  a  layer  of  cotton- wool. 
The  stupe  should  never  be  allowed  to  get  cold.  After 
the  fomentations  are  discontinued,  carefully  dry  the 
part  to  which  they  have  been  applied,  and  keep  it  cov- 
ered for  a  time  with  a  warm,  dry  flannel.  Fomenta- 
tions are  not  applied  to  discharging  wounds,  as  the 
stupes  would  at  once  be  soiled.  Their  chief  use  is  to 
relieve  spasm  of  the  internal  organs.  They  may  be 
made  more  irritant  or  sedative  by  the  addition  of  ap- 
propriate medicaments.  Twenty  or  thirty  drops  of  tur- 
pentine or  laudanum  may  be  sprinkled  over  each  stupe, 
or  it  may  be  steeped,  instead  of  pure  water,  in  some 
remedial  decoction,  as  of  poppy-heads,  hops,  or  chamo- 
mile  flowers.  A  stupe  recommended  for  a  child  con- 
sists of  Jamaica  ginger,  paregoric,  and  hot  water,  in 
equal  parts.  In  using  turpentine  there  is  some  danger 
of  blistering  the  skin,  and  any  sore  spot  must  be  first 
covered  with  some  impervious  dressing. 

When  it  is  better  to  avoid  relaxation  of  the  tissues, 
"  dry  fomentations  "  are  employed.  Toasted  flannel  is 
often  used,  but  it  does  not  retain  heat  well.  Thin  bags 
of  heated  sand,  ashes,  or  salt,  bran  or  hops,  hot  bricks, 


FOMENTATIONS,  AND  OTHER  APPLICATIONS  161 

plates,  tins,  and  water-bottles,  and  all  applications  of 
dry  heat  come  under  this  head.  The  Japanese  hand- 
warmers  are  excellent  for  this  use.  Keep  the  ventila- 
ting holes  uppermost,  and  do  not  cover  them  too  closely. 
Rubber  bags  for  hot  water  should  never  be  more  than 
half  full.  Expel  the  air  from  the  remaining  space 
before  screwing  on  the  cap.  Be  sure  that  hot  water- 
bottles  are  corked  too  tightly  to  allow  any  possibility 
of  leakage.  All  such  appliances  should  in  every  case 
have  a  covering  of  flannel  which  can  not  be  displaced. 
An  undershirt  or  large  stocking  will  serve  the  purpose. 
With  a  child,  or  an  unconscious  patient  especially,  you 
can  not  be  too  careful  about  this.  There  are  several 
cases  on  record  in  which  patients  after  an  operation, 
and  before  recovering  from  the  ether,  have  suffered 
severe  burns  in  consequence  of  an  uncovered  heater 
coming  in  contact  with  the  skin.  An  occurrence  of  this 
kind  results  from  a  degree  of  carelessness  on  the  part 
of  the  nurse  which  is  simply  unpardonable. 

Hot  applications  are  usually  better  than  cold,  the 
latter  being  used  chiefly  to  subdue  inflammation.  They 
are  good  only  in  its  earliest  and  latest  stages,  never 
when  matter  is  forming  or  during  sloughing.  To  be 
of  any  use  they  must  be  kept  cold,  and  confined  to  a 
limited  space.  If  the  treatment  is  begun  and  suspended, 
the  reaction  will  render  the  inflammation  more  severe 
than  if  it  had  never  been  undertaken. 

The  simplest  method  of  applying  cold  is  by  pieces  of 
muslin  laid  on  ice,  and  changed  for  fresh  ones  before 
they  get  warm.  This  calls  for  constant  attention.  The 
bed  must  be  well  protected ;  in  all  applications  of  water 
care  must  be  taken  that  neither  it  nor  the  patient's 
clothing  gets  wet. 

Ice  is  best  applied  in  a  rubber  bag.    These  come  in 


162  A  TEXT-BOOK  OP  NURSING 

different  shapes  to  fit  the  various  parts  of  the  body. 
The  bag  should  be  not  more  than  half  filled,  with  bits 
less  than  an  inch  square,  and  the  supply  be  renewed  be- 
fore the  last  piece  is  melted.  The  ice  will  keep  longer 
if  mixed  with  one  third  sawdust.  Put  a  muslin  cover 
on  the  ice-bag,  and  confine  it  with  a  bandage  so  that  it 
may  not  slip  about.  An  ice-bladder  for  application  to 
the  head  can  be  folded  in  a  napkin  and  pinned  in  posi- 
tion upon  the  pillow,  so  that  its  weight  will  not  press 
upon  the  head.  In  the  absence  of  a  regular  ice-cap  a 
cap-shaped  sponge  may  be  used,  which  will  absorb  the 
water  as  it  melts.  This  must,  of  course,  be  wrung  out 
before  it  is  saturated.  Ice  can  be  finely  broken  by 
wrapping  it  in  a  stout  cloth  and  pounding  it.  Coils  of 
rubber  or  lead-tubing  are  now  extensively  used  as  a 
substitute  for  the  ice-bag,  ice-water  being  siphoned 
through  them  from  a  tub  placed  at  an  elevation  above 
the  bed. 

All  evaporating  lotions  must  be  left  uncovered.  A 
single  thickness  of  lint  or  muslin  is  used,  and  frequent- 
ly wet.  Do  not  use  flannel,  or  you  may  get  a  blister. 
Such  are  alcohol,  vinegar,  muriate  of  ammonia,  etc. 

Other  lotions  are  put  on  several  folds  of  lint,  laid 
on  the  affected  part,  and  covered  closely  with  oiled 
muslin,  or  rubber  tissue.  The  lint  can  be  rewet  with- 
out taking  it  off  by  pouring  some  of  the  lotion  over  it. 

A  lotion  applied  to  the  eye  is  known  as  a  collyrium. 
Collyria  should  be  introduced  at  the  outer  angle  of  the 
eye,  either  by  a  glass  dropper,  or  a  camel's-hair  brush 
used  for  nothing  else.  Draw  down  the  lower  lid,  and 
tell  the  patient  to  look  up  at  the  instant  the  drops  are 
slid  in.  Moist  cloths  must  never  be  bound  tightly  upon 
the  eyes,  or  they  will  assume  the  nature  of  a  poultice, 
always  harmful  to  those  delicate  organs. 


COUNTER-IRRITANTS  163 

Liniments  differ  from  lotions  in  their  mode  of  appli- 
cation, being  rubbed  in  until  the  part  is  dry.  Lini- 
ments usually  contain  poisonous  ingredients,  and  must 
be  used  with  care,  the  hands  afterward  being  well 
washed  before  touching  any  sensitive  spot. 

Ointments  are  either  spread  on  lint  the  exact  size 
required  or  are  rubbed  in  like  liniments.  The  rubbing 
in  of  an  ointment  is  termed  inunction. 

Croton  oil  or  antimonial  ointment  is  rubbed  into  the 
surface  with  a  piece  of  flannel,  a  very  small  quantity  at 
a  time,  at  intervals  of  four  or  five  hours,  until  an  erup- 
tion appears.  This  is  for  counter-irritant  effect. 

Counter-irritants  relieve  inflammation  of  the  deep- 
er parts  by  causing  dilatation  of  the  superficial  capil- 
laries and  contraction  of  those  in  the  inflamed  tissues, 
probably  through  reflex  nervous  action.  There  are  two 
distinct  varieties — rubefacients,  producing  merely  local 
warmth  and  redness,  and  vesicants,  epispastics,  or  blis- 
tering agents.  Still  a  third  class  produce  a  pustular 
eruption  over  the  surface  to  which  they  are  applied. 
Of  this  kind  are  the  above-mentioned  Croton  oil  and 
tartrate  of  antimony. 

Counter-irritants  are  applied  usually  over  or  near 
the  seat  of  disorder,  but  sometimes  at  a  remote  part, 
to  obtain  what  is  called  revulsive  action.  In  this  way 
mustard  poultices  on  the  feet,  or  a  mustard  foot-bath, 
may  be  employed  for  the  relief  of  the  head. 

Mild  counter-irritation  results  from  hot  fomenta- 
tions and  poultices,  and  from  the  various  ammoniacal 
and  camphorated  liniments.  One  of  the  most  common- 
ly used  rubefacients  is  mustard.  To  make  a  mustard 
plaster  or  sinapism,  take  one  part  of  powdered  mus- 
tard and  from  two  to  five  times  the  quantity  of  flour, 
according  to  the  strength  desired.  Mix  into  a  paste 


A  TEXT-BOOK  OF  NURSING 

with  tepid  water,  and  spread  it  evenly  between  two 
pieces  of  muslin.  Hot  water  or  vinegar,  often  recom- 
mended, will  weaken  the  active  principle  of  the  mus- 
tard; and  though,  when  made  with  tepid  water,  the 
plaster  on  first  application  feels  cold,  it  soon  gets  warm. 
It  should  not  be  left  on  long  enough  to  vesicate,  as  the 
sore  produced  is  painful,  and  slow  to  heal.  From  twen- 
ty minutes  to  half  an  hour  is  usually  long  enough. 
With  an  insensible  or  delirious  patient,  the  action  must 
be  carefully  watched ;  if  neglected,  deep  ulceration  may 
ensue.  For  a  child,  it  is  well  to  mix  it  with  one  third 
glycerin  instead  of  pure  water,  as  the  action  will  be  less 
severe,  and  it  can  stay  on  longer.  Confine  in  place 
with  a  bandage.  The  burning  sensation  which  follows 
the  use  of  a  mustard  plaster  may  be  relieved,  if  ex- 
treme, by  dusting  the  part  with  flour  or  fine  starch, 
or  dressing  it  with  vaseline,  and  covering  with  cotton 
to  exclude  the  air.  Cayenne-pepper  plaster  is  made 
by  mixing  a  tablespoonful  of  Cayenne  into  a  thin  paste 
of  flour  and  water.  Spread  like  a  mustard  paste.  Or 
a  quantity  of  red  pepper  may  be  stitched  into  a  flat 
flannel  bag,  wrung  out  in  warm  water,  and  applied  over 
the  seat  of  pain.  Mustard  leaves,  mustard  paper,  and 
capsicum  plasters  are  prepared  for  use  by  simply  dip- 
ping in  tepid  water.  They  are  neat,  quickly  ready  for 
use,  and  very  effective. 

Similar  local  stimulation  may  be  obtained  from  bits 
of  cantharidal  plaster,  kept  on  for  an  hour  or  two,  but 
removed  before  the  point  of  vesication  is  reached. 
These  are  called  "  flying  blisters."  The  same  effect 
follows  the  rapid  passage  of  a  hot  iron  over  a  piece  of 
brown  paper,  or  thin  flannel,  laid  upon  the  skin.  This 
will  often  relieve  lumbago  or  chronic  rheumatism. 
Eeddening  only  is  desired.  One  use  of  the  actual 


COUNTER-IRRITANTS  165 

cautery  is  as  a  rubefacient.  The  burn  produced  by  it 
is  dressed  like  any  other  of  little  depth;  usually  with 
lint  dipped  in  a  solution  of  bicarbonate  of  soda,  and 
covered  from  the  air  with  rubber  tissue. 

To  produce  vesication,  the  agent  most  commonly 
employed  is  cantharides.  This  should  not  be  applied 
where  the  skin  is  broken  or  tender.  If  it  is  very  thin, 
as  in  case  of  a  child,  a  piece  of  oiled  tissue  paper  may 
be  interposed  between  it  and  the  cantharidal  plaster. 
This  is  said  to  lessen  the  danger  of  strangury,  while  it 
accelerates  rather  than  retards  the  action  of  the  blister, 
as  the  active  principle  of  cantharides  dissolves  in  oil 
with  great  rapidity.  The  part  should  first  be  washed 
and  dried,  shaved  if  there  is  any  hair  upon  it,  and 
the  plaster  secured  in  place  by  a  bandage  rather  than 
by  adhesive  strips,  as  the  latter  may  be  drawn  upon 
painfully  as  the  blister  rises.  This  should  take  place  in 
from  four  to  eight  hours.  If  it  does  not  rise  within 
twelve  hours,  it  should  be  removed  and  a  poultice  ap- 
plied, which  will  usually  produce  the  desired  effect.  In 
taking  off  the  plaster  be  careful  not  to  tear  the  skin, 
and  clean  off  with  a  little  oil  any  adhesive  particles. 
When  the  blister  is  well  raised,  make  a  slight  incision 
at  the  lowest  point  for  the  escape  of  the  serum,  and 
dress  with  oxide-of-zinc  powder;  or,  the  direction  may 
be  to  leave  the  blister  undisturbed,  allowing  the  fluid  to 
be  reabsorbed.  So  far  as  the  general  effect  is  concerned, 
it  is  entirely  immaterial  which  course  is  pursued.  Ill 
effects,  as  strangury  and  congestion  of  the  kidneys, 
sometimes  follow  the  prolonged  use  of  cantharides.  It 
has  been  supposed  even  to  have  induced  premature 
labor.  Camphor  corrects  the  action  of  cantharides 
upon  the  bladder.  For  this  reason,  another  method 

recommended  of  preparing  cantharidal  plaster  for  use 
12 


166  A  TEXT-BOOK  OP  NURSING 

upon  a  child  is  to  sprinkle  it  with  a  solution  of  cam- 
phor in  ether.  The  ether  will  evaporate  in  a  few  sec- 
onds, and  a  film  of  camphor  be  deposited  evenly  over 
the  surface.  A  blister  will  usually  be  raised  upon  a 
young  child  in  from  two  to  four  hours;  it  should  be 
carefully  watched,  and  not  allowed  to  remain  too  long. 
Eemove  when  the  skin  is  well  reddened,  and  poultice. 
The  cantharidal  collodion  is  a  convenient  form,  well 
adapted  to  uneven  surfaces,  as  it  can  not  get  out  of 
place.  One  or  two  coats  are  applied  by  a  camel's-hair 
brush ;  if  covered  by  oiled  silk  or  rubber  tissue  it  works 
rather  more  quickly.  The  tincture  of  iodine  is  applied 
in  the  same  way;  it  is  much  milder  in  its  action,  sev- 
eral coats  and  repeated  applications  being  usually  re- 
quired to  produce  a  blister.  If  it  burns  too  severely, 
it  can  be  washed  off  by  ammonia  or  alcohol. 

When  it  is  desirable  to  vesicate  very  quickly,  strong- 
er ammonia  or  chloroform  is  used.  A  piece  of  lint 
or  cotton  saturated  with  it  is  placed  upon  the  skin, 
its  evaporation  being  prevented  and  its  irritating  ac- 
tion limited  by  covering  it  tightly  with  a  watch-glass, 
or  the  cover  of  a  pill-box.  A  blister  will  be  raised  in 
five  or  ten  minutes.  This  method  is  always  painful; 
the  ammonia,  if  left  too  long,  will  eat  into  the  flesh. 

Blisters  should  seldom  be  used  in  the  case  of  the 
aged,  of  those  whose  circulation  is  poor,  as  they  may 
cause  extensive  sores  which  are  slow  in  healing. 

The  interior  of  the  throat  may  be  treated  by  gargles 
or  by  insufflation,  as  well  as  inhalation,  already  de- 
scribed. Gargles  are  fluids  brought  in  contact  with  the 
tonsils  and  forcibly  agitated  by  the  air  from  the  larynx. 
About  a  tablespoonful  at  a  time  should  be  used,  four  or 
five  times  successively.  After  an  acid  gargle  the  mouth 
should  be  well  rinsed  with  some  alkaline  solution,  as  bi- 


CUPS  167 

carbonate  of  soda  or  lime  water,  to  prevent  injury  to 
the  teeth. 

For  insufflation  a  rubber  air-bag  especially  designed 
for  the  purpose  may  be  used,  or  a  large  quill,  a  piece  of 
glass  tubing,  or  even  a  hollow  roll  of  stiff  paper,  filled 
with  the  prescribed  powder.  This  is  placed  as  far  as 
possible  back  in  the  throat,  and  its  contents  either 
blown  in  by  the  operator,  or  forcibly  inspired  by  the 
patient. 

The  nasal  douche,  once  so  common,  is  now  seldom 
prescribed,  as  there  is  danger  attending  its  use.  If  it  is 
followed  by  pain  in  the  ears  it  should  not  be  repeated. 
The  use  of  the  post-nasal  syringe  and  the  spray  has 
almost  entirely  superseded  that  of  the  douche. 

Cups  are  applied  to  relieve  congestion,  to  abstract 
blood,  or  to  prevent  active  absorption.  For  the  relief 
of  pain,  dry  cupping  is  the  most  practiced.  It  is  an 
operation  requiring  much  nicety  in  its  performance. 
The  articles  needed  are  cupping-glasses — in  the  absence 
of  the  regular  apparatus,  small  tumblers  or  wine-glasses 
with  smooth  edges  may  be  used — a  spirit-lamp,  a  saucer 
of  alcohol,  a  stick  with  a  bit  of  sponge  or  a  wad  of  lint 
on  the  end,  and  plenty  of  soft  towels.  The  lamp  should 
stand  between  the  patient  and  the  alcohol.  Have  the 
cups  perfectly  dry.  Dip  the  sponge  in  the  alcohol,  ig- 
nite it  from  the  lamp,  and  let  it  burn  for  an  instant  in 
the  inverted  glass;  then  withdraw  and  extinguish  it, 
at  the  same  -time  rapidly  placing  the  glass  over  the 
affected  part.  The  heat  will  have  rarefied  the  air  in 
it,  and  as  it  condenses,  on  cooling,  a  partial  vacuum  is 
formed,  to  fill  which  the  skin  will  be  forcibly  sucked  up 
and  the  blood  drawn  toward  the  surface.  Or,  instead 
of  using  the  torch,  pack  the  bottom  of  the  glass  solidly 
with  absorbent  cotton,  put  a  few  drops  of  alcohol  in  the 


168  A  TEXT-BOOK  OP  NURSING 

center,  and  ignite.  Invert  and  apply  while  still  burn- 
ing. Each  cup  may  remain  on  from  three  to  five  min- 
utes, being  removed  before  discoloration  takes  place. 
They  can  not  be  applied  over  a  bony  or  irregular  sur- 
face. A  second  cup  must  not  be  put  in  the  ring  left 
by  a  former  one.  Above  all  things,  avoid  burning  the 
patient,  either  by  using  the  alcohol  too  freely,  so  that 
it  drips,  or  by  getting  the  edges  of  the  glasses  too  hot. 
To  remove  a  cup,  make  pressure  with  a  finger  close 
to  it,  so  that  the  air  will  be  admitted.  Dry  it  well  be- 
fore using  it  again.  If  instead  of  allowing  a  cup  to 
remain  stationary,  it  be  slid  back  and  forth  along  the 
surface,  the  formation  of  effused  circles  is  avoided,  and 
a  large  tract  can  be  treated  with  one  or  two  cups.  An- 
other apparatus  consists  of  glasses  furnished  with  rub- 
ber bulbs  for  exhausting  the  air.  The  nurse  will  not 
infrequently  be  called  upon  to  practice  dry  cupping. 
Wet  cupping  is  always  attended  to  by  the  physician. 
A  scarificator,  lint,  and  adhesive  straps  will  be  required, 
in  addition  to  the  articles  already  mentioned.  After 
cupping  in  the  usual  manner,  the  scarificator  will  be 
applied,  making  a  series  of  slight  cuts.  The  glasses 
will  then  be  replaced.  Or  sometimes  the  scarificator 
will  be  applied  before  using  them  at  all.  When  suffi- 
cient blood  has  been  abstracted,  the  haemorrhage  can  be 
easily  stopped  by  pads  of  lint.  A  dry  dressing,  or  some 
simple  unguent,  is  all  that  is  needed.  Wet  cupping  is 
most  frequently  used  in  the  lumbar  region,  to  relieve 
inflammation  of  the  kidneys. 

Leeches  are  commonly  used  when  it  is  desired  to 
take  a  small  quantity  of  blood  from  any  locality.  They 
affect  a  more  limited  space,  and  are  preferable  to  cups 
if  the  parts  are  at  all  sensitive  or  inaccessible.  There 
are  two  varieties,  the  American  and  the  foreign.  The 


LEECHES  169 

former  has  three  stripes  down  the  back,  the  latter  five 
or  six.  The  foreign  leech  is  larger  and  more  voracious, 
drawing  four  or  five  times  its  own  weight  of  blood.  A 
leech  will  draw  more  blood  from  a  young  child  than 
from  an  adult,  owing  to  the  thinness  and  greater  vas- 
cularity  of  the  skin.  For  this  reason  domestic  leeches 
are  generally  chosen  for  children.  They  should  not  be 
applied  over  any  large  vessel,  but  over  a  bony  surface 
upon  which  pressure  can  be  made  in  case  of  excessive 
haemorrhage. 

There  is  sometimes  difficulty  in  making  leeches  bite. 
The  part  to  which  they  are  to  be  applied  must  be 
perfectly  clean,  washed  first  with  soap  and  water,  and 
again  with  pure  water.  The  leech  itself  should  be 
clean;  it  may  be  washed  and  dried  in  the  folds  of  a 
towel,  but  never  handled.  Strong  odors  in  the  room, 
as  of  sulphur,  vinegar,  or  tobacco  will  affect  the  leech; 
it  may  even  refuse  to  bite  when  the  patient  has  taken 
certain  drugs  internally.  Various  devices  are  proposed 
for  inducing  a  leech  to  take  hold;  a  slight  scratch,  just 
sufficient  to  give  the  taste  of  blood,  will  usually  over- 
come any  hesitation.  Near  the  eye,  or  wherever  the 
exact  spot  of  attachment  is  important,  a  test-tube, 
leech-glass,  or  small  bottle  may  be  used  to  contain  the 
leech.  If  the  leeches  are  to  be  applied  inside  the  mouth 
or  nostrils,  it  is  well  to  put  threads  through  their 
tails.  It  will  not  interfere  with  their  working,  and  will 
keep  them  from  being  swallowed.  Should  such  an  ac- 
cident occur,  they  can  be  at  once  rendered  harmless 
by  drinking  freely  of  salt  and  water.  A  leech  should 
suck  from  three  quarters  of  an  hour  to  an  hour.  If 
they  seem  sluggish,  they  can  be  excited  to  action  by 
gentle  stroking  with  a  dry  towel.  When  full  they  will 
drop  off.  If  you  wish  to  take  them  off  sooner,  sprinkle 


170  A  TEXT-BOOK  OF  NURSING 

a  little  salt  on  their  heads.  Never  remove  by  force,  or 
the  teeth  will  be  left  in  the  wound,  where  they  may 
occasion  abscess  or  erysipelatous  inflammation.  The 
leech-bite  leaves  a  permanent  stellate  scar.  The  bleed- 
ing may  be  encouraged  by  hot  fomentations  or  poul- 
tices, or  checked  if  too  profuse,  by  a  compress  of  lint, 
an  application  of  ice,  or,  if  it  resists  these,  by  touch- 
ing with  nitrate  of  silver.  A  patient  should  never  be 
left  for  the  night  till  all  bleeding  has  ceased. 

After  they  have  been  used,  the  leeches  may  as  well 
be  thrown  away,  as  it  is  only  after  a  long  time  and  con- 
siderable care  that  they  will  ever  be  good  for  anything 
again.  Leeches  not  used  may  be  kept  in  a  jar  of  w#ter, 
with  sand  and  a  little  excelsior  in  the  bottom,  and  hav- 
ing a  perforated  cover.  The  water  must  be  changed 
every  four  or  five  days.  A  piece  of  charcoal  in  the  water 
will  help  to  keep  it  pure. 

When  it  is  desired  to  draw  blood  in  greater  quantity, 
venesection  is  practiced.  A  bandage  is  twisted  tightly 
about  the  arm  above  the  spot  decided  upon.  A  vein 
is  laid  bare  by  a  half  inch  incision  along  its  course,  and 
separated  from  its  sheath.  It  is  then  opened  by  a 
knife  edge  turned  upward,  great  care  being  taken  not 
to  injure  its  posterior  wall.  From  three  to  eight 
ounces  of  blood  will  be  drawn,  the  process  requiring 
half  an  hour  or  more.  If  a  clot  should  form,  it  must  be 
removed  by  a  bit  of  aseptic  gauze.  To  check  the  flow 
of  blood,  remove  the  bandage  above,  and  apply  a  com- 
press over  the  incision. 

In  preparation  for  transfusion,  the  injection  into  it 
of  a  saline  solution,  the  vein  of  the  arm  or  leg  is  simi- 
larly dissected  from  its  sheath,  and  a  clip  applied  so 
that  the  lower  portion  will  be  filled  with  blood.  There 
is  then  inserted,  and  securely  ligated  to  it,  a  glass 


LEECHES  171 

canula  dipped  in  the  prescribed  solution.  This  is  con- 
nected by  a  rubber  tube  after  all  the  air  has  been  care- 
fully displaced  from  them  both  with  a  glass  irrigating 
flask  containing  the  solution  at  a  temperature  of  101° 
F.  The  irrigator  is  then  elevated  about  two  feet  above 
the  vein  and  the  saline  solution  allowed  to  run  into  it. 
It  will  take  about  half  an  hour  to  inject  a  quart.  At 
first  the  patient  seems  improved,  then  comes  a  critical 
period,  and  it  will  be  some  hours  before  any  marked 
benefit  is  seen.  This  treatment  is  used  to  relieve  vari- 
ous toxaemic  conditions  as  well  as  to  counteract  the 
effects  of  haemorrhage,  or  surgical  shock. 

In  such  cases,  and  in  the  collapse  of  cholera,  a  nor- 
mal saline  solution  is  sometimes  similarly  injected  into 
the  subcutaneous  tissues,  usually  of  the  thigh  or  the 
abdomen,  whence  it  is  rapidly  absorbed  by  the  vessels. 
This  is  called  hypodermoclysis.  The  absorption  is  as- 
sisted by  gentle  massage. 

In  both  these  processes,  everything  used  must  be 
thoroughly  sterilized,  and  the  greatest  care  be  taken 
that  no  air  is  injected  with  the  fluid. 

"  Look  up  and  fear  not,  do  thy  work  in  joy: 
Train  nerve  and  sinew  in  the  glad  employ 

Of  simple  souls  that  neither  strive  nor  cry. 
Drink  happy  draughts  of  love  that  will  not  cloy. 
Life  shall  not  fail  thee,  for  thy  God  is  nigh." 

W.  L.  Courtney. 


CHAPTER   XI 

"We  may  live  without  poetry,  music,  and  art; 
"We  may  live  without  conscience,  and  live  without  heart ; 
We  may  live  without  friends ;  we  may  live  without  books ; 
But  civilized  man  can  not  live  without  cooks." 

Owen  Meredith. 

ALL  animal  bodies  are  made  up  of  the  four  elements, 
oxygen,  hydrogen,  nitrogen,  and  carbon,  together  with 
a  small  quantity  of  mineral  matter.  Oxygen  and  hydro- 
gen, in  combination,  form  water,  which  enters  into  all 
constituent  parts  of  the  body,  amounting  to  more  than 
two  thirds  of  its  entire  weight.  Life  is  maintained  by 
a  continual  process  of  oxidation,  or  combustion,  pro- 
ducing heat  and  energy.  To  supply  material  for  such 
production  of  vital  force,  and  also  to  build  up  and  re- 
pair the  waste  of  the  tissues  carrying  on  the  work,  food 
is  required.  Our  food,  in  whatever  form  we  take  it,  is 
composed  of  some  or  all  of  the  four  elements  above 
named,  in  variously  proportioned  compounds. 

The  hydrocarbonaceous  compounds,  of  which  starch, 
sugar,  fat,  and  gum  are  the  most  familiar  and  most  im- 
portant, furnish  the  materials  for  oxidation,  whatever 
surplus  may  be  taken  into  the  system  being  stored  as 
fat.  These  may  be  called  the  heat-producers. 

Nitrogenous  compounds  are  more  especially  flesh- 
formers,  and  go  to  repair  the  waste  of  the  body.  The 
most  important  of  them  is  albumin,  and  the  entire 
group  of  related  compounds,  including  fibrin,  casein, 
173 


FOOD  AND  ITS  ADMINISTRATION  173 

glutin,  gelatin,  etc.,  are,  from  their  resemblance  to  it, 
frequently  termed  albuminoids. 

Neither  group  has  exclusively  the  one  function,  for 
in  the  transformation  of  albuminoids  into  living  tissue 
some  heat  is  produced;  and  in  all  healthy  tissue  there 
must  be  present,  also,  a  certain  proportion  of  the  hydro- 
carbons. But  the  division  is  still  of  value,  forming  the 
basis  of  all  scientific  dietetics. 

In  addition  to  these  two  great  groups  of  food-matter 
certain  earthy  salts  are  required — phosphorus  for  the 
nervous  system,  iron  for  the  blood,  lime  for  the  bones, 
potash  and  soda  for  the  muscles,  etc.  These  we  take 
insensibly,  they  being  more  or  less  in  nearly  everything 
we  eat  and  drink.  Common  salt  (chloride  of  sodium) 
is  the  only  one  which  we  make  a  practice  of  adding  to 
our  food. 

Hydrogen  and  carbon  very  readily  unite  with  oyx- 
gen;  it  is  a  peculiarity  of  nitrogen,  on  the  contrary, 
that  it  interferes  with  oxidation.  Entering  into  the 
composition  of  the  bodily  tissues,  it  protects  them,  so 
that  they  are  not  rapidly  consumed  by  the  heat  of  the 
oxidizing  hydrocarbons.  Their  destruction  is  generally 
slow,  and  the  amount  of  nitrogenous  matter  needed  for 
repair  is  much  less  than  the  amount  of  hydrocarbons 
called  for  as  fuel.  In  a  healthy  diet — that  is,  one  in 
which  the  supply  corresponds  to  the  demand — the  heat- 
producers  should  be  more  abundant  than  the  albumi- 
noids. In  growing  children  and  in  convalescents,  where 
disease  has  caused  undue  waste  of  substance,  the  de- 
mand for  albuminoids  is  greater. 

Even  in  health  it  is  well  to  know  something  of  the 
constituents  of  our  food,  and  what  purpose  each  serves 
in  the  economy  of  nature;  and,  when  sickness  and  its 
effects  upon  digestion  and  nutrition  are  to  be  taken  into 


174  A  TEXT-BOOK  OF  NURSING 

account,  it  becomes  worthy  of  the  most  serious  consid- 
eration. The  original  meaning  of  nurse  was  to  nourish, 
and,  in  spite  of  all  the  secondary  meanings  that  it  has 
acquired,  the  question  of  nourishment  still  remains  one 
of  primary  importance.  What  food  to  give,  when  and 
how  to  give  it,  are  constantly  recurring  problems  of  the 
sick-room. 

What  kind  of  food  is  to  be  given  in  each  case  will 
usually  be  decided  by  the  physician ;  how  best  to  prepare 
and  administer  it  are  matters  for  the  nurse  to  know. 
Everything  should  be  the  best  of  its  kind,  well  cooked, 
palatably  seasoned,  and  attractively  served.  Consult, 
as  far  as  possible,  the  known  tastes  of  the  patient;  but 
do  not  each  time  ask  him  what  he  would  like.  Some- 
thing unexpected  will  often  be  acceptable,  when  to 
have  thought  about  it  beforehand  would  have  taken 
away  all  appetite  for  it.  His  food  should  never  be  pre- 
pared in  his  presence,  nor  the  smell  of  cooking  be 
allowed  to  reach  him,  if  it  is  possible  to  avoid  it.  Your 
own  meals  should  never  be  served  in  the  sick-room;  it 
is  equally  bad  for  nurse  and  patient.  Serve  everything 
as  nicely  as  may  be,  always  with  a  clean  napkin,  spot- 
less china,  shining  silver  and  glass.  Have  the  dishes 
dry  on  the  outside,  taking  particular  care  that  nothing 
gets  spilled  from  the  cup  into  the  saucer.  This  point 
needs  special  emphasis. 

Have  hot  things  very  hot,  and  cold  ones  really  cold. 
More  salt  and  less  sugar  will  generally  be  wanted  than 
in  health.  Highly  seasoned  food  is  not  good  or  often 
wished  for,  but  everything  should  be  agreeably  flavored 
and  of  good  quality :  eggs  above  suspicion,  milk  always 
sweet,  and  butter  fresh.  The  two  articles  last  named 
ought  always  to  be  kept  cool  and  closely  covered,  for 
they  absorb  the  odors  of  whatever  is  near  them.  The 


FOOD  AND  ITS  ADMINISTRATION  175 

least  taint  in  any  kind  of  food  should  lead  to  its  rejec- 
tion, and  the  substitution  of  something  else.  Before 
taking  food  to  the  sick,  you  should  always  taste  it  to  be 
sure  that  it  is  just  right,  but  on  no  account  taste  it  in 
his  presence,  or  with  his  spoon.  Whatever  is  not  eaten 
should  be  at  once  taken  away,  as  to  leave  it  in  sight,  in 
the  hope  that  he  will  want  it  a  little  later,  is  worse  than 
useless.  It  is  always  better  to  bring  too  little  rather 
than  too  much. 

A  weak  digestion  can  not  manage  a  load,  but  must 
take  little  and  correspondingly  often.  It  is  not  wise  to 
overburden  the  patient's  stomach  in  your  anxiety  to 
make  him  take  plenty  of  nourishment,  for  it  is  not  what 
is  swallowed,  but  what  is  digested,  that  does  him  good. 
When  only  a  very  small  quantity  can  be  retained,  it 
should  be  in  a  highly  concentrated  form.  Where  there 
is  nausea  and  diarrhoea,  give  but  little  at  a  time,  and 
always  cold. 

Ascertain  from  the  doctor  how  much  he  wishes  the 
patient  to  take  within  the  twenty-four  hours,  and,  divid- 
ing it  up  into  suitable  quantities,  give  it  at  regular  in- 
tervals. The  importance  of  regularity  can  hardly  be 
too  much  emphasized.  If  given  punctually  at  fixed 
hours,  a  habit  not  only  of  taking,  but  of  digesting  it, 
will  soon  be  acquired,  for  our  most  automatic  functions 
are  influenced  by  custom.  Each  time  a  patient  is  fed,  a 
note  should  be  made  of  the  kind  and  approximate  quan- 
tity of  nourishment  taken.  Only  in  exceptional  cases 
should  he  be  roused  from  sleep  for  food,  but  a  supply 
should  be  provided  for  use  during  the  night,  as  it  may 
be  most  important  to  have  it  at  hand.  Put  it  in  the 
coolest  place,  and  cover  to  keep  out  the  dust.  Some 
light  nourishment  the  last  thing  at  night  will  often  help 
to  send  the  patient  to  sleep. 


176  A  TEXT-BOOK  OF  NURSING 

In  feeding  a  helpless  patient,  give  the  food  slowly 
and  in  manageable  quantities,  letting  each  morsel  be 
fairly  swallowed  before  another  is  given.  If  there  is 
difficulty  in  making  him  swallow,  it  will  be  lessened  by 
taking  advantage  of  his  inspirations.  See  that  the  head 
is  not  turned  to  either  side — even  a  slight  inclination 
may  cause  the  liquid  to  run  out  at  the  corner  of  the 
mouth  instead  of  down  the  throat — have  the  clothes 
well  protected,  and  take  pains  not  to  make  an  external 
application  of  it.  A  feeding-cup  with  a  spout  may  be 
used,  but,  unless  the  patient  is  able  to  control  it  him- 
self, it  has  the  disadvantage  that  the  nurse  can  not  see 
how  fast  she  is  pouring  its  contents.  Fluid  food  can 
in  most  cases  be  taken  more  conveniently  by  suction 
through  a  bent  glass  tube,  and  patients  will  often  take 
a  larger  quantity  in  this  way  than  they  can  be  induced 
to  in  any  other.  After  feeding,  always  dry  the  mouth, 
especially  at  the  corners,  if  the  patient  can  not  well  do 
it  for  himself.  The  lips  not  infrequently  become  sore 
from  want  of  this  little  care.  In  rare  cases  it  may  be 
necessary  to  give  food  by  force  to  a  delirious  patient. 
The  best  way  of  doing  this  is  through  the  nose,  the 
patient  either  lying  down  or  sitting  up  with  the  head 
thrown  back.  A  soft,  well-oiled  catheter  is  introduced 
through  the  nostril  into  the  oesophagus,  and  connected 
with  a  small  funnel  into  which  the  food — of  course  fluid 
only — is  poured.  It  should  be  introduced  at  least  fifteen 
inches  to  make  sure  that  it  has  passed  the  entrance  to  the 
windpipe.  After  once  entering  the  oesophagus,  it  will 
be  helped  down  by  the  action  of  the  constrictor  muscles. 
There  is  less  danger  of  getting  food  into  the  trachea  by 
this  method  than  by  the  use  of  a  stomach-tube  passed 
through  the  mouth.  Holding  the  nostrils  to  try  to  make 
a  patient  swallow  is  always  attended  by  some  danger. 


FOOD  AND  ITS  ADMINISTRATION  177 

With  fever,  there  is  often  great  thirst.  Usually  it 
will  be  quite  safe  to  allow  the  patient  all  the  water  he 
wants.  If  not,  it  is  worthy  of  note  that  a  small  glass 
full  will  be  much  more  satisfactory,  especially  to  chil- 
dren, than  the  same  quantity  in  a  larger  vessel.  Slight- 
ly bitter  or  acidulated  drinks  slake  thirst  more  effectu- 
ally than  water  alone.  Hot  water  quenches  thirst  better 
than  cold,  though  bits  of  ice  are  often  very  refreshing. 
They  may  be  easily  split  off  with  a  pin,  in  the  direction 
of  the  grain.  Small  bits  swallowed  whole  are  excellent 
to  control  nausea.  Sips  of  very  hot  water  are  some- 
times good  for  the  same  purpose.  Ice,  to  keep  well, 
must  be  so  placed  that  the  water  will  drain  off  as  fast 
as  it  melts.  Small  pieces  may  be  kept  in  a  glass  for 
some  time  by  suspending  them  in  flannel,  in  which  one 
or  two  holes  are  snipped  for  the  water  to  run  through. 
Confine  it  by  an  elastic  band  about  the  edge  of  the 
glass.  A  metal  spoon  in  the  glass  helps  to  melt  the 
ice  by  conducting  away  the  heat  rapidly.  A  newspaper 
wrapped  around  the  ice-pitcher,  being,  on  the  contrary, 
a  very  bad  conductor,  will  help  to  preserve  it.  Ice,  to 
be  taken  internally,  must  be  clean,  and  that  not  only 
on  the  outside.  It  is  a  great  mistake,  to  think  that  all 
deleterious  substances  are  disengaged  from  it  in  freez- 
ing. It  is  as  necessary  to  have  good  ice  as  pure  water, 
which  is  of  recognized  importance.  Pure  water  should 
be  transparent,  sparkling,  colorless,  and  odorless, 
though  these  characteristics  do  not  prove  it  such. 
Water  of  suspicious  quality,  can  be  rendered  safe  to 
use  by  boiling  it  for  half  an  hour,  and  letting  it  cool 
in  closely  covered  vessels.  It  is  always  desirable  to 
have  it  filtered. 

Water  should  be  offered  to  every  patient  several 
times  a  day,  even  if  not  asked  for,  and  its  use  encour- 


178  A  TEXT-BOOK  OP  NURSING 

aged.  Few  people  drink  as  much  as  would  be  good  for 
them. 

To  provide  food  for  the  sick  which  will  be  at  once 
suitable  and  acceptable  is  a  matter  which  requires  care, 
judgment,  and  ingenuity,  but  it  is  well  worth  the  ex- 
penditure of  them  all.  The  aim  should  be  to  give  what 
will  be  at  once  easy  of  digestion  and  of  value  after  it  is 
digested. 

Digestion  is  an  elaborate  and  complex  process,  in- 
cluding both  mechanical  and  chemical  action.  The 
saliva  contains  a  peculiar  ferment  called  ptyalin,  which 
has  the  property  of  converting  starch  into  sugar.  The 
gastric  secretion  acts  in  a  similar  way  upon  the  albumi- 
noids, changing  them  into  soluble  peptones.  The  bile, 
the  secretion  of  the  liver,  has  the  power  of  emulsion- 
izing  fats,  and  the  pancreatic  and  intestinal  juices  sup- 
plement to  a  certain  extend  the  action  of  all  the  three. 
Whatever  portion  of  the  food  resists  the  action  of  all 
these  solvents  is  rejected  from  the  system  as  waste  mat- 
ter, while  such  as  is  reduced  to  a  fit  state  of  solution  is 
absorbed  into  the  circulation.  When  the  gastric  secre- 
tion is  defective,  pepsin  may  be  given,  with  an  acid,  to 
aid  in  the  solution  of  albuminoids ;  pancreatin,  prefer- 
ably with  an  alkali,  assists  in  the  intestinal  indigestion. 

Liquid  food  is  the  most  easily  digested,  and  in  se- 
vere illness  may  be  entirely  relied  upon.  Meat  con- 
tains much  nutriment  in  small  bulk,  but  is  a  good  deal 
of  a  tax  upon  the  digestive  organs.  Vegetables  con- 
tain all  the  food  elements,  for,  as  is  well  known,  life 
can  be  sustained  on  a  purely  vegetable  diet,  but  they  in- 
clude a  large  proportion  of  waste  in  the  shape  of  indi- 
gestible fibrous  tissue.  The  leguminous  plants  are  rich 
in  albuminoids,  the  cereals  and  tubers  in  starch, 
although  wheat  contains  a  large  amount  of  glutin. 


FOOD  AND  ITS  ADMINISTRATION  1T9 

Fruits  consist  chiefly  of  water  and  sugar,  with  some 
vegetable  acid,  and  have  but  little  nutritive  value. 
Milk  is  the  only  article  of  diet  which  contains  in  itself 
all  the  necessary  elements  of  nutrition  in  their  proper 
proportions.  Tea  and  coffee  are  rather  stimulant  than 
nutrient,  but  if  not  too  strong  are  valuable  on  account 
of  the  extra  boiled  water  which  they  furnish  to  the 
system. 

Hot  water  is  almost  a  panacea,  internally  and  exter- 
nally. Cocoa  and  chocolate  are  nutritious,  but  unfor- 
tunately somewhat  difficult  of  digestion.  Eggs  are  of 
high  nutritive  value,  but  in  them,  and  in  most  other 
animal  foods,  the  albuminoids  predominate.  In  cook- 
ing eggs  in  any  way  it  should  be  remembered  that 
albumin  coagulates  perfectly  at  a  temperature  much 
below  that  of  boiling  water,  and  that  boiling  renders 
it  hard,  tough,  and  indigestible.  The  same  is  true  of 
oysters.  Beef  ranks  high  among  the  animal  foods,  but 
the  usefulness  of  beef-tea  is  very  generally  overesti- 
mated, as  the  albuminous  and  most  nutritive  portion 
of  the  meat  is  left  behind  in  its  preparation.  It  has 
value,  but  it  is  as  a  stimulant  rather  than  as  a  food. 
Preparations  of  beef  which  has  been  peptonized,  or 
partially  digested  outside  of  the  body,  are  far  superior 
to  it.  Beef-juice  may  be  given  either  hot  or  ice  cold. 
Frozen  beef- juice  will  sometimes  be  acceptable  when  it 
is  not  relished  in  the  fluid  form,  or  it  may  be  stiffened 
into  a  solid  with  gelatin. 

Broths  may  be  made  also  of  any  other  good  meat 
or  poultry.  Meat  from  which  the  juice  is  to  be  extract- 
ed must  always  be  put  into  cold  water,  and  gradually 
heated.  It  may  be  allowed  to  simmer  until  the  meat 
has  quite  lost  its  color,  but  should  never  reach  the 
boiling-point.  On  the  other  hand,  if  the  meat  itself 


180  A  TEXT-BOOK  OF  NURSING 

is  to  be  eaten,  it  should  be  in  the  beginning  exposed 
to  a  high  temperature,  which  will  coagulate  the  fibrin 
near  the  surface  and  so  prevent  the  escape  of  the  juices. 
Long,  slow  cooking  should  follow. 

All  soups  should  be  allowed  to  stand  until  cold,  as 
the  fat  can  not  be  perfectly  removed  while  hot.  Heat, 
when  required  for  use,  only  to  the  palatable  point,  with- 
out further  boiling. 

A  variety  of  gruels,  porridges,  and  panadas  are 
made  of  oatmeal,  Indian-meal,  arrow-root,  rice-flour, 
corn-starch,  etc.  Different  crushed  cereals  may  be 
obtained  already  steam-cooked,  which  will  be  found 
excellent  and  very  convenient.  Directions  for  use  are 
supplied  with  them,  but  in  most  cases  they  should  be 
allowed  more  time  than  specified  for  cooking.  It  is 
important  that  cereals  be  thoroughly  cooked.  They 
may  be  mixed  with  meat  broths,  or  with  milk  always 
being  well  cooked  first. 

Both  oatmeal  and  Indian-meal  have  a  loosening 
effect  upon  the  bowels,  and  are  consequently  objection- 
able when  there  is  any  tendency  to  diarrhosa.  In  such 
cases  boiled  milk  is  preferable  to  raw.  When  there  is 
nausea  arising  from  overacidity  of  the  stomach,  lime- 
water  may  be  added  to  the  milk,  in  any  proportion  up 
to  one  half.  If  there  is  also  constipation,  carbonic-acid 
water  or  Vichy  is  to  be  preferred.  Mineral  waters, 
both  natural  and  artificial,  are  much  used,  chiefly  as 
diuretics  and  purgatives.  They  are  of  many  varieties, 
saline,  alkaline,  sulphureted,  or  chalybeate,  and,  like 
wines,  are  to  be  classed  rather  as  medicine  than  food. 
Water  charged  with  carbonic-acid  gas,  commonly  known 
as  plain  soda,  is  the  only  one  which  a  nurse  should 
give  freely  on  her  own  responsibility.  This  is  always 
harmless  and  often  valuable,  where  there  is  feverish- 


POOD  AND  ITS  ADMINISTRATION  181 

ness,  or  an  irritable  stomach.  The  C02  can  now  be 
obtained  put  up  in  steel  capsules,  with  a  siphoned  bottle 
to  force  it  into  any  desired  fluid.  It  often  makes  milk 
acceptable  when  it  can  not  be  taken  clear.  Skimmed 
milk  can  often  be  taken  when  the  cream  can  not,  and 
it  should  be  remembered  that  this  contains  all  the  ele- 
ments of  nutrition.  Buttermilk  is  also  good. 

Koumyss  is  a  very  nutritious  and  somewhat  stimu- 
lant form  of  food.  The  original  is  prepared  in  Tartary 
from  mare's  or  camel's  milk ;  but  an  excellent  imitation 
may  be  made  by  fermenting  cow's  milk.  This  is  very 
valuable,  and  will  sometimes  be  assimilated  when  noth- 
ing else  can  be  retained.  Matzoon  is  somewhat  similar. 

Although  milk  is  a  most  healthful  and  valuable 
article  of  diet  when  fresh  and  pure  it  absorbs  noxious 
germs  from  the  atmosphere  so  rapidly  that  it  is  practi- 
cally impossible  to  keep  it  so,  even  under  the  most 
favorable  conditions,  and  it  has  often  proved  a  source 
of  danger  and  a  vehicle  for  the  transmission  of 
disease. 

Boiling  it,  or  subjecting  it  to  a  high  temperature 
in  a  steam  sterilizer,  will  destroy  the  germs  of  fermen- 
tation and  insure  against  these  elements  of  danger,  but 
it  affects  injuriously  both  the  flavor  and  the  quality  of 
the  milk.  Practically  the  same  result  with  less  altera- 
tion of  its  character  is  achieved  by  the  process  known 
as  Pasteurization,  which  consists  in  keeping  the  milk 
for  a  longer  time  at  a  lower  temperature.  A  tempera- 
ture of  170°  F.  steadily  maintained  for  twenty  minutes 
will  destroy  all  the  bacteria  that  may  be  contained  in  it, 
though  not  their  spores.  Eepeating  this  for  three  suc- 
cessive days,  allowing  the  intervals  for  the  spores  to 
develop,  will  effectively  finish  them  all.  This  is  some- 
times called  fractional  sterilization.  In  all  cases  where 
13 


182  A  TEXT-BOOK  OP  NURSING 

an  invalid  or  an  infant  is  to  be  fed  largely  upon  milk, 
it  should  be  so  treated. 

Every  nurse  should  be  a  good  cook.  It  is  a  most 
important  part  of  her  work.  A  few  recipes  for  fluid 
foods  are  subjoined.  Any  good  cook-book  will  furnish 
more  substantial  ones.  A  book  especially  to  be  recom- 
mended for  the  use  of  nurses  is  Boland's  Hand-book 
of  Invalid  Cooking,  published  by  the  Century  Com- 
pany. 

EECIPES 

1.  Beef -tea. — Take  a  pound  of  juicy  beef  cut  from 
the  round,  remove  all  the  fat,  and  cut  into  very  small 
pieces.    Put  in  an  earthen  pot  or  an  enameled  sauce- 
pan, and  add  a  quart  of  cold  water.    Cover  it  closely, 
let  it  soak  for  an  hour,  and  then  simmer  gently  for  two 
hours  more,  or  until  the  strength  is  quite  extracted 
from  the  beef.     Never  let  it  boil  hard.     Season  with 
salt  and  pepper.    Do  not  strain  it. 

2.  Beef-essence. — Mince  finely  a  pound  of  lean,  juicy 
beef,  from  which  all  the  fat  has  been  removed ;  put  into 
a  wide-mouthed  bottle  or  fruit-jar,  and  cork  tightly. 
Set  the  jar  into  a  kettle  of  cold  water  over  a  slow  fire, 
and  let  it  boil  for  three  hours.    Season  with  salt  and 
red  pepper. 

3.  Peptonized  Beef-tea. — To  half  a  pound  of  raw 
beef,  free  from  fat  and  finely  minced,  add  ten  grains  of 
pepsin,  and  three  drops  of  dilute  hydrochloric  acid. 
Put  in  a  large  tumbler,  and  cover  with  cold  water.    Let 
it  stand  for  two  hours  at  a  temperature  of  90°,  being 
frequently  stirred.    Serve  in  a  red  glass,  ice-cold.    Pep- 
tonized food  does  not  keep  well,  and  should  never  be 
used  more  than  twelve  hours  old.     The  acid  may  be 
used  without  the  pepsin  and  will  partially  digest  the 
beef. 


FOOD  AND  ITS  ADMINISTRATION  183 

4.  Beef-juice. — Place  half  a  pound  of  lean,  juicy 
beef  on  a  broiler  over  a  clear  hot  fire,  and  heat  it 
through.     Press  out  the  juice  with  a  lemon-squeezer 
into  a  hot  cup,  add  salt,  and  serve  hot  with  toast  or 
crackers. 

5.  Beef-tea  with  Oatmeal. — Mix  a  tablespoonful  of 
well-cooked  oatmeal  with  two  of  boiling  water.     Add 
a  cupful  of  strong  beef-tea,  and  bring  to  the  boiling- 
point.    Salt  and  pepper  to  taste,  and  serve  with  toast 
or  crackers.    Other  cereals  may  be  used  in  place  of  the 
oatmeal. 

6.  White  Celery  Soup. — To  half  a  pint  of  strong 
beef-tea  add  an  equal  quantity  of  boiled  milk,  slightly 
and  evenly  thickened  with  flour.     Flavor  with  celery 
seeds  or  pieces  of  celery,  which  are  to  be  strained  out 
before  serving.     Salt  to  taste. 

7.  Chicken  Broth. — An  old  fowl  will  make  a  more 
nutritious  broth  than  a  young  chicken.    Skin,  cut  it  up, 
and  break  the  bones.    Cover  well  with  cold  water,  and 
cook  slowly  for  several  hours.     Salt  to  taste.     A  little 
rice  may  be  boiled  with  it,  if  desired. 

8.  Mutton  Broth. — Cut  up  fine  two  pounds  of  lean 
mutton,  without  fat  or  skin.     Add  a  tablespoonful  of 
barley  well  washed,  a  quart  of  cold  water,  and  a  tea- 
spoonful  of  salt.    Let  it  simmer  for  two  hours. 

9.  Oyster  Tea. — Cut  into  small  pieces  a  pint  of 
oysters;  put  them  into  half  a  pint  of  cold  water,  and 
let  them  simmer  gently  for  ten  minutes  over  a  slow  fire. 
Skim,  strain,  add  salt  and  pepper. 

10.  Clam  Broth. — Take  three  large  clams,  and  let 
them  stand  in  boiling  water  until  the  shells  begin  to 
open.     Drain  out  the  liquor,  add  an  equal  quantity 
of  boiling  water,   a  teaspoonful   of   finely   pulverized 
cracker   crumbs,   a    little    butter,    and    salt    to    taste. 


184  A  TEXT-BOOK  OF  NURSING 

This    and    the    above    are    valuable    when    there    is 
nausea. 

11.  Rice  Soup. — Take  half  a  pint  of  chicken  stock 
and  two  tablespoonfuls  of  rice.    Let  them  simmer  to- 
gether for  two  hours,  then  strain  and  add  half  a  pint 
of  boiling  cream  and  salt  to  taste.    Boil  up  once,  and 
serve  hot. 

12.  Sterilized  Milk. — In  the  absence  of  special  ap- 
paratus, put  the  milk  in  ordinary  nursing  bottles,  and 
plug  them  with  absorbent  cotton.    Stand  them  in  a  ket- 
tle of  cold  water  either  on  a  wire  frame  or  a  folded 
towel  so  arranged  as  to  keep  them  from  touching  the 
bottom  of  the  kettle  or  each  other.    The  water  should 
be  deep  enough  to  cover  the  bottles  to  their  necks. 
Bring  it  nearly  to  the  boiling-point,  and  let  it  stand 
where  it  will  keep  hot  without  boiling  for  half  an  hour. 
The  temperature  should  be  170°  F.    Then  remove  the 
cotton  plugs,  cork  tightly,  and  put  the  bottles  away 
where  they  will  cool.    They  must  remain  sealed  until 
required  for  use.     Each  should  contain  only  so  much 
as  is  needed  at  one  time,  and  any  surplus  should  not 
be  offered  again.    As  soon  as  emptied,  bottles  and  corks 
must  be  most  carefully  and  thoroughly  washed,  first 
with  a  solution  of  soda  and  then  with  clean  hot  water. 
Antiseptic  cleanliness  in  every  particular  is  essential 
to  success.    The  corks  should  be  new,  and  of  good  qual- 
ity.   It  is  said  that  they  may  be  rendered  air  and  water 
tight  by  keeping  them  for  five  minutes  under  melted 
paraffin.    Eubber  stoppers  are  better  than  corks. 

13.  Peptonized  Milk. — Stir  up  five  grains  of  pancre- 
atic extract  and  fifteen  of  bicarbonate  of  soda  in  a  gill 
of  water ;  mix  thoroughly  and  add  a  pint  of  fresh  milk. 
Put  in  a  bottle  or  a  covered  jug,  and  let  it  stand  where 
it  will  keep  warm  for  an  hour.    Then  put  on  ice  until 


FOOD  AND  ITS  ADMINISTRATION  185 

required  for  use.  Milk  so  prepared  will  have  a  faintly 
bitter  flavor;  it  may  be  sweetened  to  taste,  or  used  in 
punch,  gruels,  etc.,  like  ordinary  milk. 

14.  Flour  Gruel. — Mix  a  tablespoonful  of  flour  with 
milk  enough  to  make  a  smooth  paste,  and  stir  it  into  a 
quart  of  boiling  milk.     Boil  for  half  an  hour,  being 
careful  not  to  let  it  burn.     Salt  and  strain.     This  is 
good  in  case  of  diarrhoea. 

15.  Oatmeal  Gruel. — Boil  a  tablespoonful  of  oat- 
meal in  a  pint  of  water  for  three  quarters  of  an  hour, 
then  put  it  through  a  strainer.     If  too  thick,  reduce 
with  boiling  water  to  the  desired  consistency.    Season 
with  salt. 

16.  Oatmeal  Gruel  with  Milk. — Soak  half  a  pint  of 
oatmeal  in  a  quart  of  water  overnight.    In  the  morn- 
ing add  more  water,  if  necessary,  and  boil  for  an  hour. 
Squeeze  through  a  fine  strainer  as  much  as  you  can,  and 
blend  it  thoroughly  with  a  pint  of  boiling  milk.    Boil 
the  mixture  for  five  minutes,  and  salt  to  taste. 

17.  Cracker  Gruel. — Pour  a  pint  of  boiling  milk 
over  three  tablespoonfuls  of  fine  cracker-crumbs.    But- 
ter-crackers are  the  best  to  use.    Add  half  a  teaspoon- 
ful  of  salt,  boil  up  once  all  together,  and  serve  imme- 
diately.   Do  not  sweeten. 

18.  Indian-meal  Gruel. — Mix  a  scant  tablespoonful 
of  Indian-meal  with  a  little  cold  water,  and  stir  into  a 
pint  of  boiling  water.     Boil  for  two  hours.     Strain 
and  season  with  salt.    Sugar  and  cream  may  be  added, 
if  desired. 

19.  Arrow-root. — Mix  a  teetpoonful  of  Bermuda  ar- 
row-root with  four  of  cold  milk.  Stir  it  slowly  into  half 
a  pint  of  boiling  milk,  and  let  it  simmer  for  five  min- 
utes.   It  must  be  stirred  all  the  time,  to  prevent  lumps 
and  keep  it  from  burning.    Add  half  a  teaspoonful  of 


186  A  TEXT-BOOK  OF  NURSING 

sugar,  a  pinch  of  salt,  and  one  of  cinnamon,  if  desired. 
In  place  of  the  cinnamon,  half  a  teaspoonful  of  brandy 
may  be  used,  or  a  dozen  large  raisins  may  be  boiled  in 
the  milk.  If  the  raisins  are  preferred,  they  should  be 
stoned,  and  the  sugar  may  be  omitted. 

Corn-starch  or  rice-flour  gruel  is  made  in  the  same 
way. 

20.  Sago  Milk. — Wash  a  tablespoonful  of  pearl  sago, 
and  soak  it  overnight  in  four  of  cold  water.    Put  it  in 
a  double  kettle  with  a  quart  of  milk,  and  boil  till  the 
sago  is  nearly  dissolved.     Sweeten  to  taste,  and  serve 
either  hot  or  cold. 

21.  Treacle  Possett. — Bring  a  cupful  of  milk  to  the 
boiling-point,  and  stir  into  it  a  tablespoonful  of  mo- 
lasses.   Let  it  boil  up  well,  strain,  and  serve. 

22.  Milk  and  Albumin. — Put  into  a  clean  quart 
bottle  a  pint  of  milk,  the  whites  of  two  eggs,  and  a 
small  pinch  of  salt.     Cork,  and  shake  hard  for  five 
minutes. 

23.  Koumyss. — Dissolve  a  third  of  a  cake  of  com- 
pressed yeast  (Fleischmann's),  or  its  equivalent  of  fluid 
yeast,  in  a  little  warm — not  hot — water.    Take  a  quart 
of  milk  fresh  from  the  cow,  or  warmed  to  about  blood- 
heat,  and  add  to  it  a  tablespoonful  of  sugar  and  the 
dissolved  yeast.    Put  the  mixture  in  beer  bottles  with 
patent  stoppers,  fill  to  the  neck,  and  let  them  stand  for 
twelve  hours  where  you  would  put  bread  to  rise — that  is, 
at  a  temperature  of  68°  or  70°.    Then  put  the  bottles  on 
ice,  upside  down,  until  wanted.    Open  cautiously  over 
a  bowl. 

24.  Wine  Whey. — Heat  half  a  pint  of  milk  to  the 
boiling-point,  and  pour  into  it  a  wine-glass  of  sherry. 
Stir  once  round  the  edge,  and  as  soon  as  the  curd  sepa- 
rates, remove  from  the  fire  and  strain.    Sweeten  if  de- 


FOOD   AND   ITS  ADMINISTRATION  187 

sired.  The  whey  can  be  similarly  separated  by  lemon 
juice,  vinegar,  or  rennet.  With  rennet  whey,  use  salt 
instead  of  sugar. 

25.  Mulled  Wine. — Into  half  a  cup  of  boiling  water 
put  two  teaspoonfuls  of  broken  stick  cinnamon  and 
half  a  dozen  whole  cloves.    Let  them  steep  for  ten  min- 
utes, and  then  strain.     Beat  together  until  very  light 
two  eggs  and  two  tablespoonfuls  of  sugar,  and  stir  into 
the  spiced  water.    Pour  into  this,  from  a  height,  a  cup- 
ful of  sweet  wine,  boiling  hot.     Pouring  it  several 
times  from  one  pitcher  to  another  will  make  it  light 
and  foamy.    Serve  hot.    The  wine  should  not  be  boiled 
in  tin. 

26.  Milk  Punch. — To  half  a  pint  of  fresh  milk  add 
two  teaspoonfuls  of  sugar  and  an  ounce  of  brandy  or 
sherry.    Stir  till  the  sugar  is  dissolved. 

27.  Eggnog. — Beat  up  one  egg  with  a  tablespoon- 
ful  of  sugar.     Stir  into  this  a  cup  of  fresh  milk,  an 
ounce  of  sherry,  or  half  an  ounce  of  brandy,  and  a  little 
nutmeg. 

28.  Hot  Eggnog. — Beat  together  the  yolk  of  an  egg 
and  a  tablespoonful  of  sugar,  and  stir  into  a  pint  of 
milk  at  the  boiling-point.     Add   a   tablespoonful   of 
brandy   or   whisky,   and   grate   a   little   nutmeg  over 
the  top. 

29.  Egg  Water. — Stir  the  whites  of  two  eggs  into 
half  a  pint  of  ice-water,  without  beating,  add  enough 
salt  or  sugar  to  make  it  palatable.     Good  for  teething 
children  with  diarrhoea. 

30.  Hot  Milk  and  Water. — Boiling  water  and  fresh 
milk,  in  equal  parts,  compose  a  drink  highly  recom- 
mended in  cases  of  exhaustion,  as  it  is  quickly  absorbed 
into  the  system  with  very  little  digestive  effort.    This 
is  also  true  of  the  egg  broth  above  described. 


188  A  TEXT-BOOK  OP  NURSING 

31.  Lemonade  is  best  mixed  with  boiling  water, 
even  if  to  be  taken  cold.    Strain,  sweeten  to  taste,  and 
garnish  with  a  thin  slice  of  the  lemon  cut  from  the 
center  before  it  is  squeezed. 

32.  Tamarind  Water  is  prepared  by  pouring  boiling 
water  over  preserved  tamarinds,  and  setting  aside  to 
cool. 

33.  Lime-juice  may  be  mixed  with  cold  water  and 
sweetened.    All  these  make  very  refreshing  drinks. 

34.  Honey-tea. — Strained   honey   in  hot   water   is 
sometimes  an  acceptable  beverage. 

35.  Lemonade  with  Egg. — Beat  one  egg  with  two 
tablespoonfuls  of  sugar  until  very  light,  then  stir  in 
three  tablespoonfuls  of  cold  water,  and  the  juice  of  a 
small  lemon.     Fill  the  glass  with  pounded  ice,  and 
drink  through  a  straw. 

36.  Barley  Water. — Wash  thoroughly  two  ounces  of 
pearl  barley  in  cold  water.     Add  two  quarts  of  boil- 
ing  water    and   boil    till    reduced    to    one    quart — or 
about  two  hours — stirring  frequently.     Strain,  add  the 
juice  of  a  lemon  and  sweeten.     For  infants  omit  the 
lemon. 

37.  Toast  Water. — Toast  three  slices  of  stale  bread 
to  a  very  dark  brown,  but  do  not  burn.     Put  into  a 
pitcher  and  pour  over  them  a  quart  of  boiling  water. 
Cover  closely,  and  let  it  stand  on  ice  until  cold.    Strain. 
Good  for  nausea  from  diarrhoea.     A  little  wine  and 
sugar  may  be  added  if  desired. 

38.  Apple  Water. — Slice  into  a  pitcher  half  a  dozen 
juicy  sour  apples.    Add  a  tablespoonful  of  sugar,  and 
pour  over  them  a  quart  of  boiling  water.    Cover  closely 
until  cold,  then  strain.    Slightly  laxative. 

39.  Gum-arabic  Drink. — Dissolve  an  ounce  of  gum- 
arabic  in  a  pint  of  boiling  water,  add  two  tablespoonfuls 


FOOD  AND  ITS  ADMINISTRATION  189 

of  sugar,  a  wine-glass  of  sherry,  and  the  juice  of  a  large 
lemon.    Cool  and  add  ice. 

40.  Flax-seed  Lemonade. — Into  a  pint  of  hot  water 
put  two  tablespoonfuls  of  sugar  and  three  of  whole 
flax-seed.    Steep  for  an  hour,  then  strain,  add  the  juice 
of  a  lemon,  and  set  on  ice  until  required. 

41.  Potus  Imperialis. — To  a  quart  of  boiling  water 
add  half  an  ounce  of  cream  of  tartar,  the  juice  of  one 
lemon,  and  two  tablespoonfuls  of  honey  or  sugar.    Let 
it  stand  on  ice  until  cold. 

42.  Irish  Moss. — Wash  thoroughly  a   handful   of 
Carrageen  moss,  pour  over  it  two  cups  of  boiling  water, 
and  let  it  stand  where  it  will  keep  hot,  but  not  boil,  for 
two  hours.     Strain,  add  the  juice  of  one  lemon,  and 
sugar  to  taste. 

Slippery  elm  may  be  used  in  the  same  way,  a  tea- 
spoonful  of  the  powder  to  each  cup  of  boiling  water. 

43.  Bran  Tea. — To  a  pint  of  wheat  bran  add  a 
quart  of  boiling  water.     Let  it  stand  where  it  will 
keep  hot,  but  not  boil,  for  an  hour.    Strain,  and  serve 
with  sugar  and  cream.     This  is  palatable  and  nutri- 
tious. 

44.  Corn  Tea. — Parch  brown  a  cupful  of  dry  sweet 
corn,  grind  or  pound  it  in  a  mortar.    Pour  over  it  two 
cups  of  boiling  water,  and  steep  for  a  quarter  of  an 
hour.     This  is  light  and  nutritious. 

45.  Rice  Coffee. — Parch  and  grind  like  coffee  half  a 
cupful  of  rice.    Pour  over  it  a  quart  of  boiling  water, 
and  let  it  stand  where  it  will  keep  hot  for  a  quarter  of 
an  hour.    Then  strain,  and  add  boiled  milk  and  sugar. 
This  is  nice  for  children. 

46.  Crust  Coffee. — Take  a  pint  of  crusts — those  of 
Indian-bread  are  the  best — brown  them  well  in  a  quick 
oven,  but  do  not  let  them  burn;  pour  over  them  three 


190  A  TEXT-BOOK  OF  NURSING 

pints  of  boiling  water,  and  steep  for  ten  minutes.    Serve 
with  cream. 

47.  Tea. — Tea  should  be  made  in  an  earthen  pot, 
first  rinsed  with  boiling  water.     Allow  a  teaspoonful 
of  tea  to  each  half  pint  of  water.    Put  in  the  tea,  and 
after  letting  it  stand  for  a  few  moments  in  the  steaming 
pot,  add  the  water,  freshly  boiling,  and  let  it  stand 
where  it  will  keep  hot,  but  not  boil,  for  from  three  to 
five  minutes.     Long  steeping  extracts  the  injurious 
tannin. 

48.  Coffee. — Stir   together   two   tablespoonfuls    of 
freshly  ground  coffee,  four  of  cold  water,  and  half  an 
egg.    Pour  upon  them  a  pint  of  freshly  boiling  water, 
and  let  them  boil  for  five  minutes.     Stir  down  the 
grounds,  and  let  it  stand  where  it  will  keep  hot,  but 
not  boil,  for  five  minutes  longer.    In  serving,  put  sugar 
and  cream  in  the  cup  first,  and  pour  the  coffee  upon 
them. 

49.  French    Coffee. — Some    people    prefer    filtered 
coffee  to  boiled.    This  is  made  in  a  French  biggin,  or 
a  Eussian  coffee  pot,  in  either  of  which  the  boiling 
water  percolates  through  the  pulverized  coffee.     The 
pot  is  to  be  set  where  is  will  keep  hot,  but  not  boil. 
Black  coffee  is  always  made  in  this  way. 

50.  Coffee  and  Egg. — Boil  together  for  five  minutes 
a  tablespoonful  of  ground  coffee,  a  quarter  of  an  egg, 
a  quarter  of  a  pint  of  milk,  and  a  quarter  of  a  pint  of 
boiling  water.     Beat  an  egg  and  four  teaspoonfuls  of 
sugar  together  until  stiff  and  light,  and  strain  the  boil- 
ing coffee  into  it,  stirring  all  the  time.    Add  two  table- 
spoonfuls  of  hot  cream.     This  is  only  to  be  given  in 
small  quantities. 

51.  Chocolate. — Scrape   fine   an   ounce   of  Baker's 
chocolate,  add  two  tablespoonfuls  of  sugar  and  one 


FOOD  AND  ITS  ADMINISTRATION  191 

tablespoonful  of  hot  water;  stir  over  a  hot  fire  for  a 
minute  or  two  until  it  is  smooth  and  perfectly  dissolved, 
then  pour  into  it  a  pint  of  boiling  milk,  mix  thoroughly 
and  serve  at  once.  If  allowed  to  boil  after  the  chocolate 
is  added  to  the  milk,  it  becomes  oily,  and  loses  flavor. 
A  teaspoonful  of  corn-starch,  mixed  with  a  little  cold 
water,  and  cooked  in  the  milk  before  the  chocolate  is 
added,  will  improve  the  texture  and  make  it  less  liable 
to  curdle. 

52.  Cocoa  is  chocolate  less  some  of  the  fats,  and  is 
improved  by  a  little  boiling. 

53.  Eacahout  is  a  mixture  of  chocolate  with  arrow- 
root, rice-flour,  etc.    Directions  for  use  come  with  both. 

"  They  are  as  sick  that  surfeit  with  too  much 
As  they  that  starve  with  nothing." 

Shakespean. 


RECIPES 


RECIPES 


CHAPTER   XII 

"  Talk  health;  the  dreary,  never-ending  tale 
Of  mortal  maladies  is  worn  and  stale. 
You  can  not  charm,  or  interest,  or  please 
By  harping  on  that  minor  chord,  disease. 

"  Talk  happiness ;  the  world  is  sad  enough 
Without  your  woes.     No  path  is  wholly  rough ; 
Look  for  the  places  that  are  smooth  and  clear, 
And  speak  of  those  to  rest  the  weary  ear." 

Ella  Wheeler  Wilcox. 

THE  human  skeleton  is  composed  of  more  than  two 
hundred  different  bones.  These  bones  constitute  the 
framework  of  the  body,  and  serve  to  protect  the  delicate 
vital  organs.  There  are  three  important  cavities  in  the 
body — the  skull,  the  chest,  and  the  pelvis — each  wholly 
or  partly  inclosed  by  bone,  and  held  in  position  by  the 
spinal  column.  This  itself  forms  a  canal  containing  the 
spinal  cord,  a  continuation  of  the  substance  of  the 
brain. 

The  skull  is  divided  into  two  parts:  the  cranium, 
composed  of  eight,  and  the  face,  of  fourteen  bones,  be- 
sides those  of  the  ears.  The  seams  or  lines  of  union  of 
these  bones  are  called  sutures.  That  between  the  two 
parietal  bones  is  the  sagittal  suture;  that  connecting 
the  parietals  with  the  frontal  is  the  coronal  suture; 
that  between  the  occipital  and  the  parietals,  the  lamb- 
doidal.  These  are  the  most  important  ones. 

The  head  rests  upon  the  first  of  the  spinal  vertebrae, 
194 


BONES 


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196  A  TEXT-BOOK  OF  NURSING 

which  is  called  the  atlas;  the  one  next  to  this  is  the 
axis;  these  two  allow  the  movements  of  the  head  in 
every  direction.  The  spine  consists  of  thirty-three 
bones,  called  cervical,  dorsal,  and  lumbar  vertebrae,  ac- 
cording to  the  position  which  they  occupy.  Those  of 
the  different  groups  have  differences  also  in  shape,  by 
which  they  are  recognizable. 

From  either  side  of  the  dorsal  vertebras  spring 
twelve  ribs,  forming  the  framework  of  the  thorax  or 
chest.  The  first  seven  are  connected  in  front  with  the 
sternum  or  breast-bone,  and  are  called  true  ribs;  the 
lower  five  are  distinguished  as  false  ribs,  three  of  them 
being  connected  only  with  the  costal  cartilages  in  front, 
and  the  last  two  having  no  attachment  except  to  the 
vertebrae.  These  are  termed  floating  ribs.  At  the  lower 
extremity  of  the  sternum  is  the  ensiform  cartilage. 
Joined  to  the  upper  end  of  the  sternum  in  front,  and  to 
the  scapula,  or  shoulder-blade,  in  the  back,  is  the  clavi- 
cle or  collar-bone ;  also  fitting  into  a  cavity  of  the  scap- 
ula is  the  humerus,  the  largest  bone  of  the  arm.  The 
upper  arm  has  but  this  one  bone ;  the  forearm  has  two, 
the  ulna  and  the  radius.  The  ulna  is  the  larger.  It 
makes  a  perfect  hinge-joint  with  the  humerus.  The 
two  prominences  at  the  elbow  are  called  respectively 
the  olecranon  and  the  coronoid  processes.  The  lower 
end  of  the  ulna  articulates  with  the  radius  but  does 
not  enter  into  the  wrist-joint.  This  is  formed  by  the 
lower  and  larger  extremity  of  the  radius,  articulating 
with  the  eight  small  bones  which  make  the  carpus  or 
wrist.  Besides  these  there  are  in  the  hand  five  meta- 
carpal  bones,  forming  the  palm,  and  fourteen  phalanges, 
three  in  each  finger  and  two  in  the  thumb. 

The  back  of  the  pelvic  wall  is  formed  by  the  sacrum. 
This  consists  in  early  life  of  five  distinct  bones,  which 


The  skeleton. 


14 


198  A  TEXT-BOOK  OP  NURSING 

later  become  fused  into  one.  The  coccyx,  the  extreme 
end  of  the  spinal  column,  is  also  formed  by  the  union  of 
four  small  bones.  The  remaining  walls  of  the  pelvic 
cavity  are  composed,  on  each  side,  of  three  bones,  the 
ilium,  ischium,  and  pubis,  uniting  in  adult  life  into  one, 
the  os  innominatum. 

The  lower  extremity  of  the  body  has  its  bones  ar- 
ranged very  much  like  those  of  the  arm.  The  thigh- 
bone or  femur  is  the  largest  bone  in  the  body.  It  has 
a  round  head,  which  fits  into  a  cup-like  cavity  of  the  os 
innominatum,  called  the  acetabulum;  below  this  is  a 
narrow  neck  and  two  bony  projections,  the  greater  and 
less  trochanters.  The  lower  end  of  the  femur  articu- 
lates with  the  tibia,  the  larger  bone  of  the  leg.  In  front 
of  the  knee-joint  is  a  thick  triangular  bone,  the  patella 
or  knee-pan.  Parallel  with  the  tibia  is  a  much  smaller 
bone,  the  fibula.  The  foot  has  three  divisions :  the 
tarsus,  having  seven  bones,  the  metatarsus,  of  five,  and 
fourteen  phalanges,  arranged  like  those  of  the  hand. 

The  skull  contains  the  brain  and  organs  of  special 
sense;  the  thorax,  the  organs  of  circulation  and  respi- 
ration ;  while  the  lower  part  of  the  trunk  sustains  those 
of  digestion  and  reproduction. 

The  bones  are  composed  of  about  two  parts  of  min- 
eral to  one  of  animal  matter.  Lime  is  the  main  mineral 
and  gelatin  the  prodominant  animal  constituent.  Each 
bone  is  enveloped  in  a  white  fibrous  membrane  known 
as  the  periosteum.  This  supplies  nutrition  to  the  bone. 
At  the  joints,  or  articulations,  the  bones  are  covered 
with  a  layer  of  smooth,  somewhat  elastic  cartilage,  and 
furnished  with  a  serous  membrane  which  secretes  a 
lubricating  fluid,  the  synovia.  Bones  increase  in  length 
by  the  ossification  of  these  layers  of  cartilage — a  new 
layer  being  deposited  as  the  older  one  hardens  into 


FRACTURES  199 

bone;  this  growth  is  more  rapid  at  the  lower  ends  of 
the  bones.  Similarly  they  increase  in  thickness  by  the 
continual  conversion  of  the  periosteum  into  osseus 
structure.  In  youth  the  proportion  of  animal  matter  is 
greater  than  in  advanced  life;  in  old  age  the  bones, 
lacking  the  gelatinous  element,  break  more  readily  and 
take  longer  to  unite.  Like  the  other  organs  of  the  body, 
they  are  liable  to  various  diseases  and  injuries.  Soften- 
ing of  the  bones — mollities  ossium — results  from  an  ab- 
sence of  the  normal  amount  of  mineral  deposit.  Peri- 
ostitis— inflammation  of  the  periosteum — occurs  usu- 
ally associated  with  an  inflammatory  condition  of  the 
bone  to  which  it  belongs.  Inflammation  of  the  sub- 
stance of  the  bone  itself  is  known  as  osteitis.  Caries 
is  ulceration  of  bone ;  necrosis,  death  of  the  bone  tissue 
in  mass.  This  is  most  common  in  the  shafts  of  the  long 
bones.  It  is  usually  of  traumatic  origin,  and  always 
due  to  defective  nutrition  of  the  bone.  Inflammation 
of  the  synovial  membrane  is  called  synovitis.* 

Fractures  are  the  most  common  injuries  of  bones. 
A  simple  fracture  is  one  in  which  the  bone  only  is 
divided.  When  there  is  also  a  wound  of  the  soft  parts, 
by  which  the  broken  bone  communicates  with  the  outer 
air,  the  fracture  becomes  compound.  A  flesh  wound 
existing  together  with  a  fracture  does  not  render  it 
compound  unless  it  leads  down  to  the  seat  of  fracture. 
A  multiple  fracture  is  one  in  which  the  bone  is  broken 
in  two  or  more  places.  A  comminuted  fracture  is  one 
in  which  the  bone  is  broken  into  several  small  frag- 
ments at  the  same  point.  A  comminuted  fracture  may 
be  either  simple  or  compound.  A  complicated  fracture 
is  one  in  which  some  joint  or  cavity  is  involved  in  the 

*  Note  that  the  termination  itis  always  means  inflammation. 


200  A  TEXT-BOOK  OP  NURSING 

injury.  An  impacted  fracture  is  where  one  end  of  the 
broken  bone  is  driven  forcibly  into  the  other.  In  young 
children,  whose  bones  are  soft  enough  to  bend,  we  get 
occasionally  a  partial  fracture,  of  the  convex  side  only, 
not  extending  through  the  bone.  This  is  also  called  an 
incomplete  or  green-stick  fracture.  Fractures  may  be 
transverse,  longitudinal,  or  oblique  in  direction;  the 
majority  are  more  or  less  oblique.  A  fracture  is  most 
serious  when  there  is  great  injury  of  the  soft  tissues,  or 
when  a  joint  is  involved.  The  nearer  a  large  joint  it 
occurs  the  graver  the  prognosis.  The  signs  of  fracture 
are  pain,  distortion,  loss  of  function,  or  unnatural  mo- 
bility, and  crepitus.  Crepitus  is  the  grating  made  by 
rubbing  together  the  ends  of  the  broken  bone.  It  can 
not  always  be  obtained,  as  the  fracture  may  be  impacted, 
or  some  portion  of  muscle  intervene. 

Some  special  fractures  give  special  symptoms.  A 
fractured  spine  is  indicated  by  loss  of  sensation  and 
power  of  motion  below  the  point  of  injury,  paralysis 
following  in  consequence  of  pressure  upon  or  lacera- 
tion of  the  spinal  cord.  Fracture  of  the  spine  above 
the  fourth  cervical  vertebra,  as  a  rule,  causes  instant 
death.  With  fractured  ribs,  the  patient  will  complain 
of  sharp  pain  when  he  takes  a  deep  breath  or  coughs, 
and  will  often  spit  blood.  The  danger  from  fracture 
of  the  ribs  or  sternum  is  of  injury  to  the  heart,  lungs, 
or  large  blood-vessels  by  the  broken  ends.  Fracture  of 
the  sternum  is  rare.  Ecchymosis  of  the  eye  or  behind 
the  ear,  or  the  escape  of  fluid  through  the  ear,  may  be 
a  symptom  of  fracture  of  the  base  of  the  skull.  The 
patient  may  or  may  not  be  insensible.  Fracture  of  the 
clavicle  is  one  of  the  most  common.  Those  known  as 
Pott's  and  Colles's  are  also  frequently  met.  Pott's 
fracture  is  of  the  lower  end  of  the  fibula,  usually  com- 


FRACTURES  201 

plicated  with  dislocation  of  the  ankle-joint,  and  frac- 
ture of  the  inner  jnalleolus.  Colles's  fracture  is  of  the 
lower  end  of  the  radius,  and  results  from  falling  upon 
the  hand.  Barton's  fracture  extends  obliquely  into  the 
wrist-joint,  occasioning  more  inflammation  and  greater 
impairment  of  motion  than  does  the  Colles's. 

The  process  of  repair  of  broken  bones  is,  although 
slower,  essentially  the  same  as  that  of  the  soft  tissues. 
For  the  first  two  or  three  days  after  the  injury  blood  is 
effused  around  the  broken  ends.  This  is  gradually  re- 
absorbed;  and  during  the  second  week  a  quantity  of 
lymph  is  thrown  out  between  and  around  the  fragments, 
which  by  degrees  hardens,  gluing  them  together.  This 
new  bone  material  is  called  callus;  that  between  the 
broken  ends,  intermediate  callus;  that  surrounding 
them,  provisional  callus.  When  the  fragments  can  be 
maintained  in  complete  apposition  there  will  be  no  pro- 
visional callus;  it  occurs  only  where  there  is  mobility 
of  the  broken  ends.  You  will  always  find  it  in  the  ribs, 
which  can  not  be  kept  perfectly  at  rest;  seldom  in  the 
patella,  the  olecranon,  or  the  cranium.  After  a  frac- 
ture rs  solidly  mended  the  provisional  callus  is  to  a 
large  extent  reabsorbed.  In  four  or  five  weeks  the  cal- 
lus will  usually  be  hard  enough  to  keep  the  bones  in 
place,  though  it  is  not  firm  enough  to  leave  unsupported 
tinder  six  or  eight  weeks,  and  only  becomes  converted 
into  solid  bone  after  the  lapse  of  months.  Small  bones 
unite  more  quickly  than  large  ones.  Cartilage,  once 
destroyed,  is  not  repaired. 

The  treatment  of  fractures  consists  in  putting  the 
fragments  in  proper  position,  and  keeping  them  there 
till  the  callus  has  had  time  to  form  and  harden.  For 
this  purpose  splints  are  used,  made  of  wood,  tin,  paste- 
board, gutta-percha,  leather,  felt,  or  anything  that  will 


202  A  TEXT-BOOK  OP  NURSING 

hold  the  bone  accurately  and  firmly  in  place.  A  splint 
must  be  long  enough  to  include  both  the  joints  between 
which  the  fracture  is  situated.  It  needs  to  be  well 
padded,  so  that  all  prominences  shall  be  protected  from 
pressure.  A  gutta-percha  splint  is  cut  an  inch  larger 
in  every  direction  than  the  size  required,  as  it  shrinks 
upon  soaking  in  boiling  water,  in  which  it  has  to  be  im- 
mersed to  soften  it.  It  is  then  molded  to  fit  the  part, 
and  left  on  until  cold,  when  it  will  have  hardened  into 
the  desired  shape.  It  should  afterward  be  lined  with 
chamois-skin,  and  perforated  all  over  for  ventilation. 
Sole-leather  may  be  similarly  softened  and  fitted.  It 
does  not  interfere  with  the  action  of  the  skin  so  much 
as  the  gutta-percha. 

In  place  of  such  splints  are  frequently  used  bandages 
saturated  with  starch,  glue,  or  plaster  of  Paris,  which 
harden  in  drying,  and  hold  immovable  the  part  to 
which  they  are  applied.  These,  when  thoroughly  stiff- 
ened, may  be  split  into  two  sections,  and  reapplied  as 
a  molded  splint,  held  in  place  by  additional  bandages. 
This  makes  the  limb  accessible  for  inspection  and  obvi- 
ates the  danger  of  too  much  shrinkage. 

Plaster-of-Paris  bandages  are  prepared  by  rubbing 
into  the  ordinary  coarse  brown  gauze  and  muslin  rollers 
as  much  of  the  dry  plaster  as  they  will  carry.  They  are 
then  rerolled,  and,  if  not  to  be  at  once  used,  kept  in  an 
air-tight  tin  box.  Soft  flannel  bandages  are  first  put  on 
the  broken  limb,  and  over  these  those  containing  the 
plaster,  having  been  wrung  out  in  water.  The  addition 
of  salt  to  the  water  will  cause  the  plaster  to  set  more 
rapidly.  It  usually  takes  about  twelve  hours.  Another 
way  is  to  mix  plaster  of  Paris  with  water  to  the  con- 
sistence of  thick  cream,  and  dip  in  the  mixture  folds 
of  sheet  lint  or  old  soft  cloths.  Apply  with  a  roller 


FRACTURES  203' 

bandage.  Starch  bandages  are  put  on  in  the  same  way, 
strips  of  wet  pasteboard  being  included  for  greater 
firmness.  Starch  takes  two  or  three  days  to  dry  thor- 
oughly. A  "  water-glass  "  splint  is  made  by  saturating 
white-gauze  bandages  with  a  solution  of  silicate  of  soda, 
and  applying  several  layers  of  them.  Those  on  the 
outside  should  be  cut  with  a  selvage. 

With  either  of  these,  the  broken  limb  must  be  kept 
perfectly  still  until  the  bandages  are  firm.  Sand-bags 
are  used  to  keep  them  in  position ;  if  they  are  heated  it 
will  hasten  the  drying.  The  bags  should  not  be  more 
than  three  quarters  full,  the  sand  fine  and  well  dried, 
and  the  covering  of  texture  close  enough  to  keep  it 
from  sifting  through.  Chamois-skin  is  an  excellent 
material  for  this  purpose.  If  a  plaster  splint  is  where 
it  is  likely  to  be  soiled,  it  is  well  to  brush  over  the  sur- 
face, after  it  is  dry,  with  Damar  varnish,  as  it  can 
then  be  washed.  When  a  plaster  splint  is  to  be  cut  off, 
it  will  facilitate  the  process  to  moisten  it  with  dilute 
hydrochloric  acid  along  the  proposed  line  of  incision. 
It  may  be  necessary  also  to  cut  openings  for  the  escape 
of  secretions  from  a  wound,  in  which  case  the  position 
should  be  accurately  noted  before  the  plaster  is  applied. 
But  for  a  compound  fracture  a  fracture-box  is  usually 
preferred,  as  the  wound  will  be  more  accessible.  It 
must  be  well  padded  with  bran  or  jute.  The  sides  of 
the  box  to  which  the  limb  is  bandaged  answer  the  pur- 
poses of  a  splint. 

Before  applying  any  apparatus  the  part  must  be 
carefully  washed  and  dried,  and  it  is  well  to  dust  it  over 
with  fine  starch  or  toilet-powder  to  absorb  perspiration. 
A  fractured  limb  is  extended  until  its  length,  measured 
from  fixed  points,  matches  the  corresponding  one.  If 
this  extension  can  be  kept  up  otherwise,  splints  will  not 


204  A  TEXT-BOOK  OP  NURSING 

be  required.  With  Buck's  extension,  for  thigh  fracture, 
the  leg  is  bandaged  securely  to  a  sliding  frame,  and  kept 
in  position  by  a  heavy  weight  attached  to  the  foot  and 
leg  by  adhesive  straps.  The  foot  of  the  bed  is  ele- 
vated, so  that  the  weight  of  the  body  affords  counter- 
extension. 

In  lifting  a  broken  limb,  support  the  parts  both 
above  and  below  the  point  of  fracture,  being  careful 
neither  to  shorten  nor  twist  it.  By  unskillful  handling 
a  simple  fracture  may  easily  be  converted  into  a  com- 
pound and  much  more  serious  one. 

A  dislocation  is  displacement  of  one  of  the  bony 
structures  of  a  joint  from  the  other.  It  may  be,  like  a 
fracture,  either  simple  or  compound,  or  complicated 
with  some  other  injury.  The  principal  signs  of  dis- 
location are  pain,  impairment  of  motion,  alteration  in 
the  length  of  the  limb  and  in  the  direction  of  its  axis. 
It  is  often  difficult  to  distinguish  it  from  a  fracture. 
With  a  fracture  only,  crepitus  may  usually  be  obtained, 
the  deformity  is  easily  reduced,  but  returns  as  soon  as 
the  extension  is  discontinued,  the  pain  continues  after 
reduction,  and  the  limb  is  never  abnormally  long. 
Where  a  dislocation  exists  alone,  crepitus  is  rare,  the 
deformity  is  not  easily  reducible,  but  when  reduced  is 
not  likely  to  return  at  once,  the  pain  is  always  relieved 
by  reduction,  and  lengthening  may  exist.  A  dislocation 
is  always  accompanied  by  more  or  less  laceration  of  the 
ligaments  and  contusion  of  the  adjacent  soft  tissues. 
Chloroform  or  ether  is  usually  given  to  secure  muscular 
relaxation,  and  reduction  is  then  effected  either  by 
gradual  manipulation  or  forcible  extension. 

Laceration  or  stretching  of  the  ligaments,  with 
twisting  of  the  joint,  short  of  displacement,  consti- 
tutes a  sprain.  Such  an  injury  is  very  painful,  and  it 


BANDAGING  205 

often  takes  longer  to  recover  from  it  than  from  a  frac- 
ture. The  tendency  to  inflammation  is  discouraged  by 
entire  rest,  with  elevation  of  the  sprained  joint.  Hot 
applications  afford  much  relief.  After  the  first  forty- 
eight  hours,  it  is  customary  to  support  it  by  bandaging 
or  strapping,  and  to  recommend  that  it  be  used  as  much 
as  possible,  to  prevent  stiffening. 

Abnormal  rigidity  of  a  joint,  resulting  from  injury, 
disease,  or  disuse,  is  known  as  anchylosis.  Massage  is 
a  helpful  treatment. 

Bandages  are  used  to  fix  dressings  in  place,  to  give 
support,  apply  pressure,  or  prevent  motion.  Those  in 
general  use  are  the  roller,  single  or  double,  the  many- 
tailed,  and  the  triangular  bandages.  Roller  bandages  are 
strips  of  muslin,  flannel,  or  gauze,  from  half  an  inch  to 
eight  inches  wide,  and  from  three  to  twelve  yards  long, 
evenly  and  tightly  rolled  upon  themselves.  If  made 
of  any  material  that  will  not  tear  evenly,  they  must 
be  cut  by  a  thread,  to  insure  regularity  of  width  and 
avoid  fraying  of  the  edges.  The  selvage  and  all  loose 
threads  must  be  trimmed  off.  If  a  bandage  is  to  be 
wet,  it  is  best  made  of  something  that  has  been  washed, 
or  inconvenience  may  arise  from  its  shrinkage.  An 
old  cotton  sheet  is  good  material.  To  piece  the  strips, 
lay  the  two  ends  flat  on  each  other,  overlapping  for  an 
inch,  and  baste  together  all  four  sides,  leaving  raw 
edges.  They  must  be  rolled  as  tightly  as  possible, 
either  on  a  regular  bandage  roller,  or  by  hand.  To  roll 
a  bandage  by  hand,  fold  the  end  of  the  strip  over  upon 
itself  until  you  have  a  little  roll  stiff  enough  to  keep 
its  shape.  Hold  this  perpendicularly  between  the  thumb 
and  fingers  of  the  right  hand,  letting  the  free  end  of 
the  bandage  pass  over  the  back  of  the  left  hand  between 
the  forefinger  and  thumb.  The  right  hand  should  now 


206  A  TEXT-BOOK  OF  NURSING 

be  kept  perfectly  still,  while  the  fingers  of  the  left  grasp 
the  side  of  the  roll;  a  movement  of  the  left  wrist 
rotates  it,  and  the  left  thumb  and  forefinger  regulate 
the  tension.  A  double-headed  roller  is  made  by  rolling 
a  bandage  from  both  ends  toward  the  center,  or  by 
basting  together  two  single  rollers. 

To  put  on  bandages  neatly  and  well  is  a  good  deal 
of  an  art,  and  one  for  which  no  exact  directions  can 
be  given.  There  are  a  few  general  principles  to  be 
borne  in  mind,  and  then  adaptations  are  to  be  made 

in  each  case  to  the  shape 
of  the  part  over  which  the 
bandage  is  to  be  applied, 
and  to  the  object  in  view. 
A  well-fitting  bandage  must 
lie  smoothly,  without  wrin- 
kles, making  an  even  and 
not  too  severe  pressure.  It 
must  not  be  loose  enough  to 

To  roll  a  bandage."  sliP>    nor    tight    enough    to 

be  painful  or  to  impede  the 

circulation.  A  tight  bandage  can  be  loosened  a  little 
without  removing  it,  by  cutting  half  through  each  turn ; 
but  if  this  does  not  give  sufficient  relief  it  must  be 
taken  entirely  off.  Inexperienced  bandagers  are  very 
apt  to  make  them  too  tight  in  the  effort  to  avoid 
wrinkles. 

In  putting  on  a  roller  bandage,  unwind  no  faster 
than  is  necessary,  keeping  the  roll  close  to  the  body. 
In  taking  one  off,  roll  or  gather  it  up  in  the  hand  as 
fast  as  you  unwind,  keeping  it  in  a  compact  form.  For 
bandaging  fingers  and  toes,  a  roller  half  or  three  quar- 
ters of  an  inch  wide  is  used,  for  the  hand  an  inch,  for 
the  head  or  arm  two  or  two  and  a  half  inches,  for  the 


BANDAGING 


207 


legs  two  and  a  half  and  three  inches,  and  for  the  body 
six  or  eight. 

Nearly  all  kinds  of  bandaging  are  variations  and 
combinations  of  two  simple  forms,  the  spiral  and  the 
figure-of-eight.  A 
simple  spiral  band- 
age goes  round  and 
round,  each  turn  over- 
lapping the  one  be- 
fore it  by  one  third 
its  breadth.  This  can 
be  used  over  a  nearly 
straight  part,  as  a 
finger.  To  accommo- 
date it  to  the  shape 
of  a  limb,  reverses 
have  to  be  made.  This 
is  done  by  placing  a 
finger  on  the  lower 
edge  to  hold  it  firmly, 
and  turning  the  band- 
age downward  over  itself  at  an  oblique  angle.  This 
brings  it  the  other  side  out,  and  changes  its  direction. 
These  turns  can  be  made  as  often  as  needed,  whenever 
the  bandage  will  not  otherwise  fit  smoothly.  They 
should  not  be  made  over  a  prominence  of  bone,  but  are 
best  at  the  back,  or  on  the  outer  side  of  the  limb.  The 
figure-of-eight  bandage  is  more  generally  used  than  the 
spiral,  as  it  fits  better,  and  is,  when  familiar,  more  easy 
of  application.  It  is  wound  alternately  above  and  be- 
low some  central  point,  over  which  the  roll  is  carried 
obliquely.  As  in  the  spiral,  each  turn  covers  two  thirds 
of  the  preceding.  The  angles  where  the  folds  cross 
should  be  equidistant,  and  should  succeed  each  other 


To  reverse  a  bandage. 


208 


A   TEXT-BOOK  OF  NURSING 


in  a  straight  line.  The  figure-of-eight  needs  fewer  re- 
verses than  the  spiral  bandage,  but  they  are  to  be  em- 
ployed as  occasion  requires.  The  spiral  and  the  figure- 
of-eight  may  be  used  singly  or  in  combination. 

In  bandaging  any  limb,  begin  always  at  the  extrem- 
ity, and  work  toward  the  center  of  the  body  from  left  to 
right.  Hold  the  roller  with  the  outer  side  next  the 
limb,  until  reverses  are  called  for. 

To  cover  a  foot,  start  the  free  end  of  the  bandage  at 
the  instep,  and  make  a  turn  around  the  base  of  the  toes. 
Then  carry  the  bandage  diagonally  over  the  foot,  across 
the  point  of  the  heel,  and  back  from  the  other  side  till 
it  coincides  with  the  first  turn.  Cover  this,  and  carry 

a  second  turn  around  the^ 
heel,  half  an  inch  higher 
than  the  first;  continue  to 
make  alternate  turns  un- 
der the  sole  and  behind 
the  heel,  crossing  over  the 
instep,  until  the  entire 
foot  is  covered.  Finish 
with  a  couple  of  circular 
turns  around  the  ankle,  or 
continue  up  the  leg.  For 
covering  the  leg,  the  spiral 
bandage  may  be  used  with 
a  succession  of  anterior 
reverses,  or  a  continuous 
figure-of-eight.  When  the 
bandage  is  completed,  the 

effect  to  the  eye  will  be  the  same  whichever  method  is 

adopted,  but  the  latter  will  be  far  more  secure,  and  will 

make  more  even  pressure.    It  is  always  to  be  preferred. 

In  finishing  off  a  bandage,  make  one  or  two  straight 


BANDAGING  209 

turns,  fold  under  the  end  and  pin  it,  or  split  the  last 
quarter  of  a  yard  through  the  middle,  wind  the  ends  in 
opposite  directions  around  the  limb,  and  tie  them  in  a 
bow.  To  apply  a  bandage  over  a  movable  joint,  as  a 
knee,  make  first  a  circular  turn  directly  over  the  center 
of  the  joint,  then  apply  the  figure-of-eight  alternately 


Mode  of  application  of  a  hinge-joint  bandage. 

above  and  below  it,  close  enough  to  have  the  edges  meet 
and  entirely  cover  the  first  turn.  This  will  allow  some 
freedom  of  motion  without  displacing  the  bandage. 

A  bandage  to  cover  the  groin  is  commenced  with 
two  turns  about  the  thigh;  the  roller  is  then  carried 
diagonally  to  the  opposite  hip,  round  the  waist,  and 
downward,  crossing  the  first  oblique  fold  in  front  of  the 
thigh.  Another  turn  about  the  thigh  follows  in  the 
same  direction  as  the  first,  and  the  same  course  is  re- 
peated, leaving  proper  spaces  and  making  a  series  of  fig- 
ures-of-eight,  till  the  bandage  is  carried  sufficiently  far. 


210  A  TEXT-BOOK  OF  NURSING 

A  bandage  of  this  form,  a  figure-of-eight  which  includes 
two  distinct  parts  of  the  body,  is  called  a  spica.    This 

may  be  used  either  by  itself 
or  as  a  continuation  of  the 
leg  bandage. 

In  bandaging  over  a 
splint,  where  great  firmness 
is  required,  the  best  result 
is  obtained  by  alternating 
figures-of-eight  with  circular 
turns,  which  keep  them  from 
slipping.  This  makes  a  very 
secure  bandage,  but  not  a 
good  one  to  use  directly  upon 
the  flesh,  as  the  pressure  is  unequal. 

To  bandage  a  hand,  begin  at  the  tip 
of  the  first  finger,  and  cover  it  by  a 
succession  of  close  spirals  or  figures-of- 
eight  to  its  base.  Then  make  a  turn 
around  the  wrist  to  keep  these  from 
slipping,  and  return  to  the  root  of  the 
second  finger.  Lead  the  bandage  by  one 
or  two  spirals  to  the  tip  of  this,  and 
then  proceed  down  it,  as  upon  the  first 
finger,  concluding  with  another  turn 
about  the  wrist.  Cover  each  finger  suc- 
cessively in  the  same  way.  Then  take 
Spica  on  the  thigh,  a  slightly  wider  bandage,  start  it  at  the 

with    foot  and    b     k      f  th     ^      d          d  wind   it   armmd 
leg  bandage. 

the  base  of  the  fingers.  Carry  it  ob- 
liquely across  the  back  of  the  hand,  around  the  wrist, 
back  to  the  further  side,  and  again  around  the  palm. 
Continue  these  turns  alternately  till  you  have  a  line  of 
crosses  straight  down  the  back  of  the  hand,  and  the  palm 


BANDAGING  211 

is  completely  covered.  The  thumb  is  finally  to  be  dressed 
by  making  alternate  turns  over  it  and  around  the  wrist. 


To  bandage  fingers.  To  cover  the  palm. 

This  is  sometimes  called  the  spica  for  the  thumb.  Before 
covering  the  palm  of  the  hand,  put  a  little  absorbent  cot- 
ton in  it.  Do  the  same  at  the  flexures  of  any  large  joint 
that  is  to  be  covered  by  a  bandage, 
to  make  it  fit  better,  to  absorb  per- 
spiration, and  prevent  chafing.  This 
is  especially  important  at  the  axilla. 
A  spica  for  the  shoulder  may  be 
put  on  in  much  the  same  way  as 
that  for  the  thigh,  beginning  with 
one  or  two  turns  around  the  arm, 
carrying  the  bandage  over  the  point 
of  the  shoulder,  across  the  back,  un- 
der the  other  arm,  and  over  the 
chest  to  the  shoulder  again.  Make 
another  turn  about  the  arm,  and  re- 
peat three  or  four  times  as  required.  Spica  for  the  thumb. 


212 


A  TEXT-BOOK  OP  NURSING 


Single  shoulder  spica. 


A  double  spica  for  the  shoulders,  which  includes 
the  entire  chest,  is  commenced  like  the  single  spica,  but 

the  second  turn  across  the 
back,  instead  of  following 
in  the  line  of  the  first,  is 
carried  down  at  a  sharper 
angle,  and  brought  around 
the  waist.  It  is  then  car- 
ried again  diagonally  up 
the  back  to  the  opposite 
shoulder.  Make  two  or 
three  turns  about  this  arm, 
as  previously  around  the 
other,  then  carry  the  band- 
age down  across  the  chest, 
around  the  waist,  and  up 
across  the  chest  again  to  the  shoulder  from  which 
it  started.  Wind  it  again  about  the  arm,  carry  it 
obliquely  down  the 
back,  around  the 
waist,  etc.,  leaving  the 
usual  spaces,  and  fol- 
lowing the  direction 
of  the  previous  turns, 
till  the  entire  chest  is 
covered.  There  should 
then  be  a  line  of 
crosses  in  the  center 
of  the  front,  in  the 
back,  and  down  each 
shoulder. 

An  admirable  band- 
age for  the  arm  and  shoulder,  in  case  of  clavicle  frac- 
ture, devised  by  the  late  Dr.  C.  H.  Wilkin,  of  New 


Double  shoulder  spica. 


BANDAGING 


213 


York,  is  applied  as  follows:  Place  the  arm  of  the  in- 
jured side  on  the  opposite  breast.  Start  the  bandage 
in  the  middle  of  the  back,  between  the  shoulder-blades, 
and  bring  it  over  the  well  shoulder  near  the  neck  down 
to  the  outside  of  the  injured  arm  just  above  the  elbow. 
Then  bring  it  under  the  elbow,  leaving  the  tip  exposed, 
and  up  over  the  injured  shoulder  to  the  starting-point, 
where  it  is  pinned  to  the  first  end  of  the  roller.  Con- 
tinue downward  across  the  back,  and  round  the  body 
in  a  straight  line,  over 
the  injured  arm,  just 
above  the  elbow  -  tip. 
Carry  it  round  twice  in 
the  same  place,  and  the 
second  time  cross  the 
back  upward  to  the  well 
shoulder,  and  down  again 
to  the  outside  of  the  in- 
jured arm,  and  around 
the  elbow  as  before,  leav- 
ing the  proper  spaces. 
This  is  the  best  of  the 


Wilkin's  clavicle  bandage. 


numerous  bandages  in  use  for  fractures  of  the  clavicle. 
Before  applying  any  of  them,  a  thick  wedge — which 
may  be  made  of  a  folded  towel — is  placed  close  under 
the  arm  so  as  to  throw  it  slightly  outward,  and  bring 
the  fractured  ends  into  proper  position. 

The  roller  bandage  may  be  so  applied  as  to  fur- 
nish support  to  one  or  both  breasts,  being  put  on  either 
as  a  figure-of-eight  passing  around  the  neck  or  as 
a  spica  including  the  shoulders.  Firm  and  even  pres- 
sure can  be  made  upon  the  breasts  by  a  single  broad 
band  passing  around  them,  the  spaces  between  and 

at  either  side  being  first  filled  to  a  level  with  cot- 
15 


214 


A  TEXT-BOOK  OF  NURSING 


Breast  bandage. 


ton.    Straps  over  the  shoulders  will  help  to  keep  this 

in  place. 

The  figure-of-eight  for  the  head  is  one  of  the  most 

useful  bandages  for  re- 
taining dressings  upon 
the  scalp.  This  is  put 
on  as  follows:  Start  the 
bandage  over  the  ear, 
holding  the  roll  toward 
the  face.  Carry  it  across 
the  eyebrows,  then 
around  the  back  of  the 
head  as  high  as  possi- 
ble. Continue  to  wind 
it  round,  making  each 
turn  a  little  higher  in 

front  and  a  little  lower  in  the  back  until  you  have  cov- 
ered as  much  surface  as  is  required.     Another  is  the 

Capelline.    This  is  put  on  by  a 

double  roller,  one  end  of  which 

needs  to  be  a  third  larger  than 

the   other.      Stand   behind  the 

patient,  and,  taking  the  smaller 

roll  in  the  right  and  the  other 

in  the  left  hand,  begin  low  on 

the   forehead   and   carry   them 

round  the  head  as  far  down  on 

the  occiput  as  possible.     Then 

transfer  the  bandage  in  the  left 

hand  to  the  right,  and  continue 

it    round,   while    the    other   is 

folded  over  at  right  angles  with 

it,  and  brought  across  the  top  of  the  head  to  the  front 

in  the  left  hand.    Here  it  meets  the  other  and  crosses 


Figure-of-eight  on  head. 


BANDAGING 


215 


it,  again  running  backward,  and  overlapping  the  former 
folds.  These  turns  are  continued  until  the  whole  head 
is  covered,  one  bandage  going 
round  and  round  it  and  the 
other  back  and  forth  across  it. 
All  the  folds  leading  from  the 
front  of  the  head  to  the  back 
should  be  on  the  left  of  the 
middle,  while  those  leading  to- 
ward the  front  should  be  on 
the  right.  Finish  with  one  or 
two  extra  circular  turns.  The 
head  may  be  partially  or  en- 
tirely covered  by  a  single 
roller,  making  alternately  cir- 


Capelline. 


cular   and  oblique   turns,   and   pinned   at  the   angles. 

To  bandage   a  stump  after  amputation,  either  a 
single  or  a  double  roller  may  be  used  in  much  the 
same  way  as  in  bandaging  the 
head,   beginning   at   some   dis- 
tance   from    the    end,    making 
turns  back  and  forth  over  it, 
and    holding    them    firmly    by 
circular  ones. 

The  figure-of-eight  may  be 
so  applied  as  to  cover  the  eye, 
and  is  often  so  used.  Bandages 
for  the  eye  should  always  be 
light.  After  the  operation  for 
cataract,  a  single  straight  strip 
of  muslin  is  used,  furnished 
'with  tapes  to  tie  behind. 

When  it  is  important  to  avoid  motion  of  the  part  to 
be  covered,  a  "many-tailed"  bandage  may  be  used. 


Cataract  bandage. 


216 


A  TEXT-BOOK  OF  NURSING 


This  consists  of  a  piece  of  muslin  torn  into  strips  from 
each  side  to  within  an  inch  or  two  of  the  center,  which 
.  is  left  entire.  Apply  this  to  the  back  of  the  limb,  an<J, 
beginning  at  the  bottom,  fold  the  strips  from  either 
side  alternately  around  it,  giving  them  an  upward 

direction,  and  mak- 
ing them  cross  each 
other  in  front.  The 
bandage  of  Sculte- 
tus  is  an  improve- 
ment upon  this.  To 
_______  prepare  it,  take  a 

Many-tailed  bandage.  gtrjp    fae    length    Of 

the  part  to  be  bandaged,  and  sew  across  it  at  right  an- 
gles other  strips  overlapping  each  other  by  two  thirds 
their  width.  Without  turning  this  round,  lay  it  on  a 
board,  to  keep  it  smooth,  and  slide  it  under  the  limb; 
begin  at  the  bottom,  and  fold  the  strips  one  after  an- 
other in  a  slanting  direction  over  it.  The  strips  from 
opposite  sides 
should  cross  in 
front  and  go  half- 
way round  again. 
This  bandage  can 
be  applied  with 


Bandage  of  Scultetus. 


very  little  disturb- 
ance to  the  patient, 
the  limb  having 
only  to  be  slightly 
lifted  to  slip  the  board  under  and  again  to  remove  it. 
The  following  form  may  be  used  after  ovariotomy  and 
other  abdominal  operations.  Take  nine  strips  of  flan- 
nel, each  four  inches  wide  and  one  yard  and  a  half  long. 
Place  two  of  these  lengthwise  on  a  table  at  a  distance 


BANDAGING 


217 


of  six  inches  apart.  Sew  the  other  seven  across  them, 
beginning  at  the  top  and  allowing  each  to  overlap  the 
one  above  it  by  a  little  more  than  half.  Pass  the  band- 
age under  the  body,  fold  the  cross  strips  over  the  ab- 
domen from  below  upward,  then  bring  the  free  ends  of 
the  vertical  strips  be- 
tween the  thighs,  and 
pin  them,  one  on  each 
side  to  the  front.  These 
will  keep  the  bandage 
from  slipping  up  or 
wrinkling  under  the 
back.  This  arrange- 
ment has  the  advantage 
of  allowing  the  wound 


T  bandage. 


to    be   dressed   without 

moving  the  patient.    It 

is  sometimes  used  as   a  substitute   for  the   ordinary 

binder  after  confinement.     Other  modifications  of  the 

many-tailed  bandage  are  made  to  fit  different  parts  of 

the  body. 

The  T  bandage  is  constructed  on  the  same  plan, 
but  consists  of  two  pieces  only,  at  right  angles  to  each 

other.  Its  chief 
use  is  to  retain 
dressings  upon 
the  perinaeum. 

A  four-tailed 

bandage  is  made  by  splitting  a  strip  of  muslin  at  each 
end  to  within  a  few  inches  of  the  center.  Such  a  one 
may  be  used  to  keep  dressings  on  or  gives  light  sup- 
port to  the  knee.  Place  the  center  over  the  patella, 
carry  the  tails  under  the  knee,  cross  them  so  that  the 
lower  ones  will  come  above  the  joint,  and  the  others 


Four-tailed  bandage. 


218 


A  TEXT-BOOK  OP  NURSING 


below,  bring  them  round,  and  tie  in  front,  two  above 

and  two  below  the  knee.  The  same  bandage  may  be  so 
adjusted  as  to  support  one  breast,  the 
center  being  placed  under  it,  the  two 
lower  tails  meeting  over  the  opposite 
shoulder,  while  the  upper  ones,  cross- 
ing them,  join  under  the  arm. 

For  the  jaw,  take  a  strip  a  yard 
long  and  three  inches  wide,  make  a  slit 
of  three  inches  in  the  center,  and  split 
the  ends  to  within  two  inches   of  it. 
Let  the  chin  rest  in  this  slit,  carry  the 
two  lower  halves  up  in  front  of  the  ears, 
and  tie  them  together  on  top  of  the 
head,  while  the  upper  ends  are  carried 
back  below  the  ears  and  tied  together 
behind.     Finally,  bring  these  ends  ver- 
Four-tailed  band-   tically  upward,  and  knot  them  again 
age  on  knee.      jn^o  the  corresponding  ones  from  above. 
Eetractors  are  wide  bandages  having  two  or  three 

tails,  slit  at  one  end  only,  used  during  amputations  to 

keep  the  soft  parts  out 

of   the   way   while   the 

bone  is  being  sawed. 
These    are    only    a 

few  of  the  many  ways 

in  which  the  roller  and 

the    many-tailed    band- 

ages may  be  used.     The 

triangular  bandage  can 

also  be  applied  in  many 

different      forms,      and 

can    anywhere    be    pro- 

vided by  folding  or  Cut- 


Four-tailed  breast  bandage. 


BANDAGING 


219 


o 


ting  a  large  handkerchief  diagonally.  On  the  head,  it 
forms  the  covering  known  as  a  shawl  cap.  Place  the 
center  in  the  middle  of  the  forehead,  let  the  ends  cross 
low  down  at  the  back  of  the  head,  catching  in  the  apex 
of  the  triangle,  and 
bring  them  round 
again  to  be  tied  in 
front.  In  an  exact- 
ly similar  way  it 
may  be  used  to  re- 
tain the  dressing 
on  a  stump.  To 
keep  dressings  in  Ketractors. 

the  axilla,  fold  over  the  rectangular  corner  of  the  tri- 
angle, place  the  center  under  the  arm,  cross  the  ends 
over  the  shoulder  above,  and  bring  them  down,  one 
across  the  chest  and  one  across  the  back,  to  be  tied 
together  under  the  opposite  arm. 

It  may  be  applied  as  a  sling  to  the  upper  extremity 
in  three  ways.  If  the  fore- 
arm is  injured,  its  whole 
extent  should  be  supported 
equally,  including  the  el- 
bow. Carry  the  outer  end 
of  the  sling  around  the  neck, 
on  the  side  to  which  the  in- 
jured arm  belongs,  and  the 
end  between  the  hand  and 
the  chest  around  the  other 
side,  tying  them  at  the  back. 
If  the  injury  is  of  the  up- 
per arm,  the  sling  should 

support  the  wrist  only,  making  no  pressure  on  the 
elbow.  Turn  the  hand  with  the  palm  toward  the  chest, 


Shawl  cap. 


220 


A  TEXT-BOOK  OF  NURSING 


and  support  it  higher  than  the  elbow.    Cross  the  ends 
in  the  opposite  direction  from  that  above  described. 


Sling  for  forearm. 

With  a  fractured  clavicle  or  scapula,  the  front  of  the 
sling  should  bind  the  elbow  well  forward,  and  cover  the 
hand,  crossing  upon  the  opposite  shoulder  the  other 


Sling  to  support  upper  arm. 


BANDAGING 


221 


end,  brought  up  obliquely  across  the  back,  and  tied  with 
it  under  the  sound  arm.  A  foot  may  be  slung  by  a  wide 
bandage  passing  around  the  neck. 

Rubber  bandages  are  most  used  to  reduce  or  prevent 
swelling.  They  should  be  put  on  without  reverses,  and 
special  care  is  needed  to  avoid  getting  them  too  tight. 
Elastic  stockings  are  used  for  the  same  purpose,  usually 
in  case  of  varicose  veins. 

Another  means  of  affording  support,  or  protection, 
to  a  limb,  or  other  part,  is  by  strapping  with  adhesive 
plaster.  Cut  the  strips  in  the  direction  of  the  selvage, 


Sling  for  fractured  clavicle. 

which  must  be  taken  off.  Warm  by  holding  the  plain 
side  over  the  flame  of  a  spirit  lamp,  or  on  a  bottle  of 
hot  water.  If  it  is  to  be  applied  over  a  very  uneven 
surface,  immerse  it  in  hot  water  and  press  it  gently  on 
with  a  cloth.  For  strapping  a  leg,  cut  the  strips  an  inch 
and  a  half  wide,  and  long  enough  to  lap  over  six  inches 
after  passing  around  the  limb.  The  hair  should  first  be 
shaved  off.  Stand  in  front  of  the  patient,  and  apply 


222  A  TEXT-BOOK  OF  NURSING 

the  middle  of  the  strap  to  the  back  of  the  leg;  bring 
the  ends  around  and  cross  them  in  front,  giving  them 
an  upward  direction,  like  the  sections  of  a  many-tailed 
bandage.  The  next  strip  is  put  on  a  little  higher,  over- 
lapping the  first  by  a  third,  and  so  on,  as  far  as  required. 
For  joints,  the  strapping  should  extend  for  some  dis- 
tance above  and  below,  and  the  plaster  is  best  spread 
on  leather. 

In  case  of  fractured  ribs,  or  whenever  it  is  desired 
to  limit  the  movements  of  the  chest,  strapping  is  some- 
times employed  in  place  of  bandaging.  It  has  an  ad- 
vantage in  that  it  can  be  applied  to  one  side  alone. 

Adhesive  plaster  can  now  be  procured  already  pre- 
pared for  use,  wound  upon  metal  spools,  a  much  more 
convenient  form. 

"Habit  is  a  cable;  we  weave  a  thread  of  it  each  day,  and  it 
becomes  so  strong  we  can  not  break  it." — Horace  Mann. 


CHAPTER   XIII 

"  Learning  anew  the  use  of  soldiership, 
Self-abnegation,  freedom  from  all  fear, 
Loyalty  to  the  life's  end." 

Robert  Browning. 

AMONG  the  responsibilities  which  have  been  men- 
tioned as  pertaining  to  the  nurse,  there  is  none  of 
greater  gravity  than  the  prevention  of  contagion.  The 
atmosphere  is  everywhere  more  or  less  laden  with  the 
minute  organisms  known  as  bacteria  or  microbes. 
These  are  the  lowest  forms  of  vegetable  life. 

An  individual  bacterium  is  a  single  cell  of  colorless 
protoplasm  without  a  nucleus,  either  spherical,  cocco, 
or  in  the  form  of  straight  rods,  bacilli.  They  multiply 
very  rapidly,  either  by  fission  or  by  the  formation  of 
spores.  Moisture  is  essential  to  their  growth;  dryness 
holds  them  quiescent.  Freezing  does  not  injure  them, 
but  heat  and  light  are  destructive  to  them.  The  spores 
have  more  persistent  vitality  than  their  parent  organ- 
isms. Microbes  are  not  all  of  an  infectious  nature,  but 
among  them  are  the  germs  of  various  diseases.  Their 
chief  function  is  to  disintegrate  and  destroy  dead  ani- 
mal and  vegetable  matter.  In  the  course  of  their  work 
certain  highly  poisonous  chemical  products  are  evolved, 
known  as  ptomaines,  or  toxins. 

One  class  of  pathogenic  bacteria  produces  inflam- 
mation and  suppuration  in  a  wound.  These  will  be 
further  considered  when  we  take  up  the  subject  of  sur- 
gical nursing. 


224:  A  TEXT-BOOK  OF  NURSING 

Infectious  diseases  are  propagated  by  the  agency  of 
such  living  particles,  given  off  from  the  body  of  the 
sick,  and  conveying  the  specific  poison.  They  may  lie 
dormant  for  a  time,  but  under  suitable  conditions  de- 
velop and  multiply,  reproducing  the  original  disease. 
In  some  cases  the  conditions  of  development  are  found 
within  the  body,  and  the  disease  can  be  directly  trans- 
mitted from  one  person  to  another,  while  in  others  the 
germ  only  originates  in  the  body,  and  requires  to  be 
developed  outside  before  it  becomes  infectious.  Of  the 
latter  class  are  typhoid,  yellow  fever,  cholera,  dysen- 
tery, and  the  plague,  while  all  the  other  diseases  com- 
monly recognized  as  infectious  are  contagious  as  well — 
that  is,  capable  of  direct  transmission.  They  are  all 
caused  by  the  presence  of  specific  bacteria  in  the  tis- 
sues. All  contagious  diseases  are  infectious,  but  all 
infectious  diseases  are  not  contagious.  The  latter 
term  is  applied  only  to  those  which  may  be  transmitted 
from  a  sick  to  a  well  person  by  direct  contact,  while 
those  which  spread  indirectly  through  food,  water,  soil, 
etc.,  are  called  infectious.  Miasmatic  diseases,  of  which 
malaria  is  a  typical  example,  result  from  the  entrance 
of  infectious  agents  from  without,  and  can  not  always 
be  traced  directly  or  indirectly  to  another  case  of  the 
same  kind.  f 

After  exposure  to  contagion,  some  time  is  required 
for  the  development  of  the  infectious  germs  before  they 
actively  manifest  themselves.  This  interval,  during 
which  the  poison  remains  latent,  is  known  as  the  period 
of  incubation.  It  varies  in  different  diseases,  and  even 
in  different  cases  of  the  same  disease,  though  each  has 
its  own  characteristic  type  and  mode  of  development. 
The  germs  of  small-pox  or  scarlet  fever  may  be  carried 
about  indefinitely,  or  lie  hidden  in  a  room  or  in  clothes 


CONTAGION  AND  DISINFECTION  225 

for  months,  and  then  under  suitable  conditions  mani- 
fest the  greatest  virulence. 

Diseases  which  attack  many  people  at  the  same  time 
are  termed  epidemic;  those  confined  to  particular  local- 
ities are  endemic.  Sporadic  cases  are  such  as  occur 
singly,  and  independently  of  any  recognized  infectious 
influence. 

Disinfectants  are  such  substances  as  act  upon  the 
specific  contagia  of  communicable  disease,  and  destroy 
them,  or  render  them  inert.  They  are  to  be  carefully 
distinguished  from  antiseptics,  preventives  of  decompo- 
sition, and  from  deodorants,  which  merely  subdue  dis- 
agreeable smells.  Some  of  the  latter  may  be  useful  in 
absorbing  deleterious  gases,  but  they  have  no  effect 
upon  the  solid  particles  which  convey  infection. 

Abundant  oxygen  is  the  best  disinfectant;  it  decom- 
poses the  septic  germs,  as  it  does  all  other  organisms. 
Boiling  for  half  an  hour  will  destroy  the  activity  of  all 
known  disease  germs,  though  in  some  cases  their  spores 
have  a  greater  resisting  power.  It  is  believed,  how- 
ever, that  exposure  to  steam  at  a  temperature  of  230° 
F.  will  be  fatal  to  these  also.  Dry  heat  is  less  effec- 
tive than  moist,  therefore  steaming  is  surer  than  bak- 
ing. For  this  purpose  especially  made  steam  sterilizers 
are  used,  or  for  small  articles  the  ordinary  steamer 
used  for  cooking,  tightly  closed,  will  answer  equally 
well.  Fifteen  minutes  over  vigorously  boiling  water 
will  destroy  whatever  pathogenic  germs  may  be  shut 
up  in  it.  In  large  establishments,  steam  under  pres- 
sure is  used  in  a  closed  chamber,  giving  a  still  higher 
temperature. 

Whenever  any  directly  communicable  disease  is 
found  to  exist,  the  first  thing  to  be  done  is  to  isolate,  as 
completely  as  possible,  the  patient  and  his  attendants. 


226  A  TEXT-BOOK  OP  NURSING 

There  should  be  two  nurses  for  every  such  case,  that 
each  may  get  the  daily  open-air  exercise  which  is  more 
than  ever  important,  and  neither  be  obliged  to  sleep  in 
the  infected  room.  They  should  avoid  contact  with  all 
outsiders  as  much  as  possible,  and  always  change  their 
clothes  upon  going  out.  The  hair,  which  can  not  be 
changed,  should  be  covered  with  a  close  cap.  Nothing 
should  be  worn  in  the  room  which  may  not  afterward 
be  washed  or  destroyed. 

The  directions  given  for  the  arrangement  of  a  sick- 
room apply  with  the  greatest  force  in  these  cases.  All 
superfluous  things,  particularly  such  as  can  not  be 
washed,  must  be  taken  out  of  the  room  before  the  pa- 
tient is  put  in  it.  After  he  is  once  quarantined,  every 
article  carried  out  of  the  room  must  be  disinfected.  A 
set  of  dishes  should  be  kept  for  his  exclusive  use,  and 
washed  by  the  nurse.  The  bedding,  clothing,  etc.,  must 
not  be  sent  to  the  general  laundry,  but  washed  by  them- 
selves after  being  well  soaked  in  some  disinfecting  solu- 
tion. For  any  minor  dressings,  and  in  the  place  of 
handkerchiefs  when  there  is  a  discharge  from  the 
throat  or  nose,  use  old  soft  cloths  that  can  be  imme- 
diately burned.  All  excrementitious  and  vomited  mat- 
ter must  be  disinfected  with  the  greatest  care. 

There  is  nothing  small  enough  to  be  careless  about. 
Even  the  broom  which  sweeps  the  floor  should  not  be 
used  again  elsewhere.  Do  not  let  the  air  blow  from  the 
sick-room  into  the  rest  of  the  house  any  more  than  can 
not  be  avoided.  It  helps  to  keep  the  air  pure  to  hang 
about  the  room  cloths  kept  wet  with  some  disinfectant. 
Over  the  doorway  may  be  hung  a  sheet  similarly  damp- 
ened. This  has  at  least  an  excellent  moral  effect,  and 
moral  influences  are  not  without  value  in  dealing  with 
contagion.  While  neglecting  no  possible  precaution, 


CONTAGION  AND  DISINFECTION  227 

try  not  to  create  unnecessary  alarm.  People  afraid  of 
infection  are  predisposed  to  it  by  acquiring  a  nervous 
condition  which  renders  them  doubly  susceptible.  Yet 
the  danger  is  not  to  be  underrated,  and  insufficient  pre- 
cautions may  actually  be  worse  than  none,  giving  an 
unfounded  sense  of  security. 

Take  good  care  of  yourself  as  well  as  your  patient, 
for  the  confinement  and  the  isolation  make  these  cases 
doubly  wearing.  Try  to  secure  rest  and  nourishing 
food  at  regular  hours,  and  do  not  let  the  trouble  of 
having  to  change  your  clothes  hinder  you  from  getting 
out  of  doors  every  day,  even  if  you  are  tired.  A  brisk 
walk  in  the  fresh  air  is  the  best  possible  disinfectant 
for  yourself. 

So,  also,  the  best  way  of  disinfecting  the  air  of  the 
sick-room  is  by  exchanging  it  for  pure  air.  Air  can  not 
be  renewed  by  disinfecting  it,  any  more  than  it  can  be 
disinfected  by  deodorizing.  Neither  process  renders  it 
fit  to  breathe  again.  In  all  cases  of  infectious  disease 
free  ventilation  is  of  the  first  importance.  In  those  dis- 
eases in  which,  as  in  scarlet-fever  and  small-pox  the 
infectious  particles  are  largely  thrown  off  by  the  skin, 
a  good  deal  can  be  done  toward  keeping  the  air  pure 
by  inunction  of  the  skin  with  carbolized  ointment,  and 
by  frequent  bathing  and  changing  of  the  clothes. 

The  burning  of  pastilles,  cascarilla  bark,  etc.,  serves 
rather  to  add  to  than  to  remove  the  impurities  of  the 
air.  Charcoal  or  peat,  placed  about  the  room  in  shal- 
low pans,  does  absorb  a  certain  amount  of  poisonous 
matter.  Carbolic  crystals  exposed  in  an  open  dish,  or  a 
carbolic  solution  sprinkled  about  the  room  and  on  the 
screens  and  outer  covers  of  the  bed,  will  quickly  cor- 
rect any  offensive  odor;  but  neither  of  these  is  to  be 
regarded  as  a  disinfectant.  Solutions  of  sulphate  of 


228  A  TEXT-BOOK  OF  NURSING 

iron,  nitrate  of  lead,  and  permanganate  of  potash,  and 
the  various  chlorides  of  lime,  soda,  and  zinc,  similarly 
used,  do  act  as  true  disinfectants,  the  former  gradually 
giving  off  oxygen  and  the  latter  absorbing  carbonic- 
acid  gas  and  liberating  chlorine;  but  as  they  affect  only 
the  air  coming  in  contact  with  them  their  influence 
is  not  far-reaching.  The  vapors  of  iodine  and  bromine 
and  the  fumes  of  nitrous  acid  have  vigorous  disinfect- 
ing qualities,  but,  as  commonly  employed,  they  are  only 
deodorants,  as  they  can  not  be  used  in  the  sick-room 
in  quantity  enough  to  be  useful  without  exciting  dan- 
gerous bronchitis.  Indeed,  any  gaseous  disinfectant,  to 
be  effective,  must  be  used  in  quantity  incompatible 
with  human  presence.  Chlorine,  sulphurous-acid  gas, 
and  formaldehyde  are  the  three  commonly  employed. 

The  most  powerful  and  rapid  of  the  liquid  disinfect- 
ants in  general  use  is  the  solution  of  bichloride  of  mer- 
cury (corrosive  sublimate).  It  is  also  a  valuable  anti- 
septic. The  solution  ordinarily  used  is  of  the  strength 
of  1  to  1,000,  about  fifteen  grains  to  the  quart.  This 
may  be  used  for  disinfecting  vessels,  sinks,  and  drains; 
but  not  for  clothing,  as  it  makes  an  indelible  stain.  For 
the  latter  purpose  may  be  used  a  solution  of  sulphate  of 
zinc  and  common  salt,  four  ounces  of  the  sulphate  and 
two  of  the  salt  to  a  gallon  of  hot  water.  Soak  the 
clothes  in  this  for  two  hours,  and  then  boil  them  with 
soda  or  borax.  Dry  in  fresh  air.  Common  washing 
soda,  a  2-per-cent  solution  at  212°  F.,  is  an  excellent 
disinfectant  for  instruments  and  utensils,  and  good  for 
general  scrubbing,  being  a  germicide,  as  well  as  an 
effective  cleansing  agent,  but  it  is  likely  to  have  a 
deleterious  effect  on  clothing. 

Cond/s  fluid  (solution  of  permanganate  of  potash) 
is  often  recommended,  but  it  can  hardly  be  used  strong 


CONTAGION  AND  DISINFECTION  229 

enough  to  do  any  good  without  staining.  The  sulphate 
of  iron  (copperas)  should  remove  such  stains,  but  itself 
discolors.  Stains  from  copperas  can  be  taken  out  by 
oxalic  acid  or  lemon  juice.  Carbolic  also  decomposes 
Condy's  fluid,  and  is  incompatible  with  chlorine,  so  that 
it  must  not  be  used  in  combination  with  either  of  them. 
Chlorine  and  sulphurous  acid  mutually  destroy  each 
other.  Chlorine  is  soluble  in  water  to  the  extent  of  two 
and  a  half  volumes;  the  solution  can  be  used  as  a  disin- 
fectant for  clothing,  etc.  It  is  decomposed  by  the  ac- 
tion of  light. 

Copperas  or  chloride  of  lime  may  be  thrown  dry 
into  water-closets  and  drains  with  good  effect.  They 
should  afterward  be  thoroughly  flushed.  For  privy 
vaults  and  cesspools,  use  four  pounds  of  copperas  dis- 
solved in  one  and  a  half  gallons  of  water  to  every  cubic 
yard  of  contained  space.  A  little  disinfectant  should 
be  kept  standing  in  all  sputa-cups,  urinals,  and  bed- 
pans, ready  for  use.  For  this  purpose  the  tincture  of 
iodine,  or  Condy's  fluid,  is  excellent.  The  latter  may 
be  known  to  have  lost  its  efficiency  when  it  has  lost  its 
color. 

A  good  disinfectant  is  made  by  dissolving  half  a 
drachm  of  nitrate  of  lead  in  a  pint  of  boiling  water, 
then  dissolve  two  drachms  of  common  salt  in  eight  or 
ten  quarts  of  water.  "When  both  are  thoroughly  dis- 
solved, pour  the  two  mixtures  together,  and  when  the 
sediment  has  settled  you  have  a  pail  of  clear  fluid,  which 
is  the  saturated  solution  of  the  chloride  of  lead.  A 
cloth  saturated  with  the  liquid  and  hung  up  in  a  room 
will  at  once  sweeten  a  fetid  atmosphere;  poured  down  a 
sink,  water-closet,  or  drain,  or  on  any  decaying  or  offen- 
sive object,  it  will  produce  the  same  result.  The  nitrate 

of  lead  is  very  cheap,  and  a  pound  of  it  would  make 
16 


230  A  TEXT-BOOK  OP  NURSING 

several  barrels  of  the  disinfectant.  Creolin,  a  thick 
fluid,  resembling  crude  carbolic  acid,  possesses  high  dis- 
infecting properties.  As  it  does  not  mix  readily  with 
water  it  is  commonly  used  in  the  form  of  an  emulsion 
of  two-  to  five-per-cent  strength.  This  should  always 
be  well  shaken  before  using,  and  thoroughly  mixed  with 
the  substance  to  be  disinfected.  Any  albuminous  mate- 
rial in  the  mass  will  interfere  with  its  action. 

With  disease  which  is  only  indirectly  infectious — as 
typhoid  and  cholera — isolation  of  the  patient  is  not 
necessary;  but  the  greatest  care  is  essential  in  disinfect- 
ing those  discharges  from  the  body  which  contain  the 
germs  of  contagion.  All  excrementitious  matter  must 
be  disinfected  and  disposed  of  thoroughly  and  promptly. 
For  stools,  cover  the  bottom  of  the  receiving  vessel  with 
a  layer  of  copperas  or  chloride  of  lime  before  use.  After 
use,  add  crude  hydrochloric  or  sulphuric  acid,  in  quan- 
tity equal  to  half  the  bulk  of  the  discharge,  cover  close- 
ly, and  carry  at  once  from  the  room.  These  stools  must 
not  be  emptied  into  the  common  closet.  The  best  way 
to  dispose  of  them  is  to  mix  with  sawdust  and  burn 
them.  All  clothing  and  bedding  soiled  even  in  the 
slightest  degree  with  the  discharges  must  be  disinfected 
with  equal  care  and  boiled.  These,  measures,  rigidly 
taken,  will  prevent  the  spread  of  such  disease,  unless 
there  is  some  local  cause  for  it. 

When  a  patient  has  died  from  any  infectious  dis- 
ease the  body  should  be  washed  with  some  disinfectant. 
Labarraque's  solution  is  commonly  used.  The  burial 
should  be  as  soon  as  possible,  and  strictly  private. 

After  a  case  is  ended,  whether  by  death  or  recovery, 
the  room  must  be  subjected  to  a  thorough  process  of 
cleaning  and  fumigation.  Everything  that  can  be  so 
treated  should  be  boiled,  or  baked  in  a  disinfecting 


CONTAGION  AND  DISINFECTION  231 

oven,  at  a  temperature  of  not  less  than  220°  F.  The 
floor,  woodwork,  and,  if  possible,  the  walls  should  be 
scrubbed  with  some  disinfectant,  the  mattresses  taken 
to  pieces  for  fumigation,  and  the  bedding  washed.  Rub- 
ber sheets  and  aprons  are  best  cleaned  with  Labar- 
raque's  solution;  they,  of  course,  can  not  be  baked. 
Everything  that  can  not  be  otherwise  thoroughly  dis- 
infected should  be  hung  up  in  the  room  while  it  is 
being  fumigated.  All  drawers  and  closets  should  be 
left  wide  open,  that  the  gas  may  penetrate  to  every 
corner.  Sulphurous-acid  gas,  chlorine,  or  formalde- 
hyde, may  be  used  for  fumigation;  the  latter  is  now 
usually  preferred.  The  first  two  are  powerful  bleach- 
ing agents,  and  will  discolor  metals,  so  that  all  metallic 
surfaces  should  be  first  covered  with  a  coating  of  grease 
to  protect  them  when  either  of  these  is  used.  Chlorine 
is  very  destructful  to  fabrics. 

To  fumigate  a  room  or  ward  with  sulphur,  close  the 
doors,  windows,  and  fireplace,  and  paste  paper  closely 
over  all  the  cracks.  Put  the  sulphur  in  iron  pans,  al- 
lowing two  pounds  for  every  thousand  cubic  feet  of 
space.  Set  the  pans  in  larger  pans  of  water,  and  these 
on  bricks  so  as  not  to  burn  the  floor;  pour  a  little  alco- 
hol over  the  sulphur  and  ignite,  beginning  with  the 
pan  farthest  from  the  door  by  which  you  are  to  make 
your  exit.  Leave  the  room  quickly,  and  paste  up  this 
door  like  the  others.  Keep  it  closed  for  twenty-four 
hours;  then  open  all  the  windows,  and  let  the  room  air 
for  as  much  longer. 

When  chlorine  is  used,  the  same  precautions  must 
be  taken  against  its  escape.  The  materials  for  its  pro- 
duction are  better  placed  in  the  higher  parts  of  the 
room  than  on  the  floor,  as  the  gas  is  heavier  than  air. 
The  following  is  the  best  way  to  procure  it  in  quantity: 


232  A  TEXT-BOOK  OP  NURSING 

Mix  a  pound  each  of  common  salt  and  the  black  oxide 
of  manganese  in  a  shallow  earthen  dish,  add  two  pints 
of  sulphuric  acid,  previously  diluted  with  two  pints  of 
water,  and  stir  with  a  stick.  Chlorine  is  irrespirable. 
If  it  becomes  necessary  to  enter  a  room  full  of  it,  hold 
near  the  nostrils  a  handkerchief  wet  with  dilute  am- 
monia, but,  when  possible,  the  windows  should  be  left 
so  that  they  can  be  opened  from  the  outside. 

The  efficiency  of  both  sulphur  and  chlorine  is  in- 
creased by  the  presence  of  steam;  the  latter  especially 
requires  a  certain  amount  of  moisture  in  the  air.  For- 
maldehyde is  now  more  used  than  either.  This  is  a 
gas  obtained  when  a  current  of  air,  charged  with  the 
vapor  of  methyl  alcohol,  is  directed  on  an  incandescent 
spiral  of  platinum  wire.  A  saturated  solution  of  it  in 
water,  which  will  contain  about  forty  per  cent,  is  called 
formalin.  It  may  also  be  had  in  the  form  of  solid  com- 
pressed tablets. 

Formaldehyde  rapidly  destroys  bacteria  in  an  in- 
closed space,  but  it  is  not  to  be  relied  upon  to  penetrate 
substances,  so  that  when  it  is  used  for  fumigation,  all 
clothing,  mattresses,  pillows,  etc.,  should  also  be  dis- 
infected by  steam. 

The  gas  is  obtained  either  by  the  slow  combustion 
of  methyl  alcohol  in  specially  prepared  lamps,  or  by 
liberating  it  by  the  action  of  heat  from  the  liquid  or 
solid  forms.  The  latter  is  the  preferred  method.  For- 
malin or  formochloral  is  placed  in  autoclaves,  tightly 
closed  receptacles,  and  brought  to  a  high  temperature 
under  pressure.  When  sufficiently  heated,  the  gas  is 
liberated  by  opening  a  valve,  and  conveyed  through  a 
tube  into  the  apartment  to  be  disinfected.  In  another 
form  of  apparatus,  a  sufficiently  high  temperature  to 
dissociate  the  gas  is  obtained  by  passing  its  watery  solu- 


CONTAGION  AND  DISINFECTION  233 

tion  through  a  highly  heated  metal  coil,  similarly  con- 
nected with  a  delivery  tube. 

The  solid  tablets  are  decomposed,  setting  free  the 
gas  by  simply  heating  them  in  an  open  vessel  over  a 
free  flame.  Sixty  of  these  should  be  used  for  every 
thousand  cubic  feet  to  be  disinfected.  For  the  same 
space,  a  quart  of  methyl  alcohol  should  be  burned,  or 
a  pound  of  formalin  evaporated. 

The  room  should  be  prepared  as  in  other  modes  of 
fumigation  by  tightly  closing  every  aperture  for  the 
escape  of  gas,  and  taking  precautions  against  fire  by 
placing  a  piece  of  sheet  iron,  or  a  large  tin  pan,  under 
the  apparatus  in  the  middle  of  the  room.  Ignite,  and 
make  your  escape.  Generators  of  thr  gas  from  the 
aqueous  solution  must  be  set  at  work  in  an  adjoining 
room,  to  be  under  control,  and  connected  by  a  tube 
through  the  keyhole  with  the  one  to  be  fumigated.  Ten 
per  cent  of  glycerin  added  to  the  formalin  will  make 
it  more  effective.  Keep  the  room  closed  for  twelve 
hours,  then  air  thoroughly,  and  sprinkle  with  ammo- 
nia water  to  remove  the  odor. 

"  Early  and  provident  fear  is  the  mother  of  safety." — Burke. 


CHAPTER   XIV 

"  In-seeing  sympathy  is  hers,  which  chasteneth 

No  less  than  loveth,  scorning  to  be  bound 
With  fear  of  blame,  and  yet  which  ever  hasteneth 
To  pour  the  balm  of  kind  looks  on  the  wound." 

J.  R.  Lowell. 

WOUNDS  of  all  kinds,  with  the  diseases  resulting 
from  them,  and  such  others  as  are  treated  by  operative 
or  mechanical  means,  come  under  the  head  of  surgical 
cases.  A  wound  is  defined  as  a  solution  of  continuity 
of  the  soft  parts.  It  may  be  of  any  degree  of  severity, 
from  a.  slight  contusion  to  an  extensive  laceration. 

An  incised  wound  is  a  simple  smooth  cut,  like  that 
of  a  knife,  and  is  dangerous  in  proportion  to  its  depth. 
If  the  edges  are  torn,  the  wound  is  described  as  lacer- 
ated. A  lacerated  cut  will  be  more  painful  than  a 
sharp  incision  of  the  same  extent,  but  the  haemorrhage 
will  be  more  easily  controlled.  A  contusion  or  bruise 
is  a  subcutaneous  laceration.  It  will  occasion  more  or 
less  extravasation  of  blood,  known  as  ecchymosis.  If 
the  contusion  is  accompanied  by  a  rupture  of  the  in- 
tegument, the  discoloration  will  be  less,  as  the  effused 
blood  and  serum  find  an  outlet.  This  constitutes  a 
contused  wound.  It  is  usually  made  by  some  blunt  in- 
strument. The  tissues  may  be  crushed  beyond  recov- 
ery, in  which  case  ulceration  sets  up  around  the  dead 
parts,  and  they  become  gradually  separated.  Such 
separation  is  known  as  sloughing.  All  lacerations  par- 
234 


SURGICAL  NURSING  235 

take  of  the  character  of  contused  wounds,  as  there  is 
more  or  less  bruising  about  the  sides  and  edges.  Gun- 
shot wounds,  being  made  by  blunt  bodies,  are  prac- 
tically tubular  contused  wounds.  They  are  very  pain- 
ful, and  likely  to  be  accompanied  by  a  deep-seated 
inflammation,  as  they  usually  contain  foreign  matter. 
Punctured  wounds  are  those  made  by  sharp-pointed  in- 
struments. If  of  any  depth,  they  are  dangerous,  from 
the  variety  of  tissues  involved,  and  from  the  want  of 
a  free  vent  for  any  discharge  that  may  be  set  up.  Slight 
wounds  may  be  rendered  more  serious  by  the  introduc- 
tion into  them,  either  at  or  after  the  time  of  injury, 
of  some  poison  or  virus. 

Burns  are  dangerous  in  proportion  not  so  much  to 
their  depth  as  to  the  extent  of  surface  involved.  A 
burn  covering  half  the  surface  of  the  body  will  result 
in  death  from  shock;  recovery  is  very  rare  if  so  much 
as  one  third  of  it  is  burned.  Burns  are  sometimes 
classified  as  of  three  degrees:  The  first  is  a  mere  red- 
dening, with  slight  swelling,  owing  to  distention  of  the 
capillary  blood-vessels.  It  is  sometimes  followed  by 
desquamation  of  the  cuticle.  If  the  heat  applied  has 
been  a  little  greater  there  will  be  a  rapid  flow  of  fluid 
out  of  the  distended  capillaries,  and  blisters  will  be 
formed  containing  serum,  or  serum  mixed  with  blood. 
These  may  be  raised  immediately,  or  after  a  few  hours. 
With  a  burn  of  the  third  degree  the  injury  is  still  more 
severe,  so  as  to  destroy  the  vitality  of  the  part.  The 
gangrenous  portion  then  gradually  sloughs  off,  with 
free  formation  of  pus,  and  the  wound  heals  slowly  by 
granulation.  The  cicatrix  of  a  burn  has  a  strong  dis- 
position to  contract,  and  often  produces  great  deform- 
ity. Severe  burns  are  not  infrequently  complicated  by 
inflammatory  affections  of  the  internal  organs,  The 


236  A  TEXT -BOOK  OF  NURSING 

lungs  and  kidneys  often  become  deranged  in  their  ac- 
tion, and  gastric  disorders  are  common.  Perforating 
ulcer  of  the  duodenum  occurs  seldom  earlier  than  the 
tenth  day  after  injury. 

Scalds  are,  in  effect,  similar  to  burns,  and  frost-bites 
are  analogous.  Of  the  latter  there  are  two  degrees:  one 
in  which  vitality  is  merely  suspended,  the  parts  being 
white,  stiff,  and  numb,  and  developing  an  inflammatory 
tendency  upon  return  of  the  circulation;  and  a  second 
degree,  in  which  the  vitality  is  completely  destroyed, 
and  gangrene  supervenes  upon  thawing. 

There  are  five  modes  described,  by  either  of  which  a 
wound  of  the  soft  tissues  may  heal.  1.  By  primary 
union,  where  two  cleanly  cut  surfaces,  brought  into 
close  contact,  simply  grow  together,  without  suppura- 
tion. This  is  also  called  healing  by  first  intention. 
Wounds  of  the  perinaeum  and  of  the  face  and  throat 
are  most  likely  to  heal  in  this  manner.  2.  When  union 
by  first  intention  does  not  take  place,  there  may  still 
be  primary  adhesion.  A  layer  of  lymph  exudes,  gluing 
together  the  surfaces  of  the  wound,  which  then  unite 
promptly.  3.  In  the  process  of  granulation,  the  wound 
is  gradually  filled  up  to  the  surrounding  level  by  new 
tissues,  appearing  in  the  form  of  small,  red,  close-set 
granules  bathed  in  pus.  4.  In  secondary  adhesion,  two 
granulating  surfaces,  brought  together,  unite.  5.  Under 
a  scab,  where  the  effusion  of  lymph  forms  a  thick  film, 
under  which  the  healing  process  goes  on,  the  surface 
of  the  sore  contracting  and  acquiring  a  new  skin.  It 
takes  a  cicatrix  a  long  time  to  acquire  the  vitality  of 
the  original  structure,  if,  indeed,  it  ever  does. 

For  ordinary  purposes  it  is,  perhaps,  sufficient  to 
classify  wounds  as  healing  by  first  intention  or  by  gran- 
ulation, without  going  further  into  detail.  Destruction 


SURGICAL  NURSING  237 

of  the  external  tissues,  attended  by  secretion  of  pus,  is 
ulceration. 

Granulations,  if  deficient,  can  be  encouraged  by 
stimulating  applications,  or  be  checked,  if  excessive,  by 
astringents.  Nitrate  of  silver  is  most  often  used  for 
the  latter  purpose. 

The  healing  of  a  granulated  surface  may  be  has- 
tened by  skin-grafting,  which  consists  in  placing  upon 
it  small  portions  of  skin  freshly  cut  from  some  part  of 
the  patient's  or  some  other  individual's  body.  If  the 
operation  is  successful,  each  graft  becomes  a  center 
around  which  cicatrization  takes  place,  thus  rapidly 
diminishing  the  size  of  the  ulcer.  The  resulting  cica- 
trix  possesses  more  vitality,  and  is  less  liable  to  contract, 
than  that  which  results  from  the  ordinary  healing  proc- 
ess. In  deep  ulcers,  prepared  sponge  is  sometimes  used 
for  grafting.  This  is  invaded  by  the  granulations, 
and  is  subsequently  absorbed.  Antiseptic  precautions 
must  be  taken  in  grafting. 

The  healing  process  is  often  hindered  by  inflamma- 
tion, a  series  of  changes  in  the  blood  and  the  tissues 
resulting  from  irritation  or  specific  poison,  and  mani- 
fested by  heat,  redness,  swelling,  pain,  and  suppuration. 
The  swelling  will  be  greatest  and  the  pain  least  where 
there  is  the  most  loose  tissue;  in  a  bony  or  fibrous  tis- 
sue inflammatory  pain  is  very  severe.  Inflammation 
attacking  a  mucous  membrane  is  of  less  importance 
than  when  a  serous  membrane  or  solid  part  is  affected, 
as  the  matter  can  find  its  way  to  the  surface  by  one  of 
the  natural  outlets;  otherwise  it  is  pent  up  in  a  cavity, 
or  in  the  substance  of  some  organ.  An  accumulation 
of  pus  in  any  of  the  tissues  or  organs  of  the  body  is  an 
abscess.  In  opening  an  abscess  a  free  incision  should 
always  be  made  at  the  lowest  point.  The  common  but 


238  A  TEXT-BOOK  OF  NURSING 

reprehensible  plan  of  making  a  small  opening  and  forci- 
bly squeezing  out  the  contents  of  an  abscess  has  been 
aptly  termed  "  surgical  barbarism  "  (Gerster).  If  it  is 
left  to  break  spontaneously,  the  resulting  scar  will  be 
larger  than  if  it  is  cut.  When  the  pus  manifests  a 
tendency  to  work  toward  the  surface,  it  is  said  to  be 
"  pointing."  No  wound  should  ever  be  allowed  to  heal 
at  the  surface  first,  as  there  will  then  be  no  outlet  for 
the  imprisoned  matter,  and  it  will  "  burrow  "  inwardly, 
doing  further  injury.  Drainage  tubes  are  sometimes 
used  to  keep  wounds  open  until  they  heal  from  the  bot- 
tom, and  to  carry  off  the  pus.  They  are  most  often  of 
rubber  or  glass,  with  holes  in  the  sides,  so  that  the  pus 
may  flow  in  from  every  direction.  Strips  of  iodoform 
gauze  are  used  for  the  same  purpose. 

Pus  is  a  thick,  cream-colored,  opaque  discharge, 
smooth,  slightly  glutinous,  and  insoluble  in  water.  The 
formation  of  pus  is  accompanied  by  pain  and  throbbing, 
and,  if  extensive,  with  fever,  and  sometimes  chills  or 
rigors.  It  is  a  steady  drain  upon  the  system,  and  a 
patient  suffering  from  a  suppurating  wound  needs  to 
have  his  strength  kept  up  by  the  most  nourishing  food. 

Foreign  matters  in  a  wound,  or  retained  and  re-ab- 
sorbed secretions,  may  give  rise  to  general  inflamma- 
tory fever.  To  prevent  the  retention  and  consequent 
decomposition  of  discharges,  and  to  protect  from  ex- 
ternal contamination,  are  the  main  points  of  the  local 
hygiene  of  surgery. 

The  treatment  of  wounds  consists  in  checking  the 
haemorrhage,  removing  foreign  matters,  bringing  sepa- 
rated surfaces  into  apposition,  and  excluding  the  air  by 
some  aseptic  dressing.  Decomposed  animal  matter  is 
one  of  the  most  virulent  of  poisons,  and  the  smallest 
particle  of  it  carried  from  one  case  to  another  may  suf- 


SURGICAL  NURSING  239 

fice  to  set  up  inflammatory  action.  Great  care  is  needed 
to  guard  against  this  in  a  surgical  ward.  Two  bad 
cases  should  not  be  put  in  adjoining  beds,  when  it  can 
by  any  possibility  be  avoided,  and  the  proportion  of 
suppurating  wounds  in  the  ward  ought  not  to  exceed 
one  third.  All  instruments — scissors,  forceps,  etc. — 
used  about  the  dressing,  even  of  a  healthy  wound,  must 
be  thoroughly  cleaned  before  they  are  put  away  or  used 
again.  If  oil  or  vaseline  is  required,  do  not  allow  fin- 
gers to  be  put  into  the  common  bottle,  but  take  out  a 
little,  and  throw  away  all  that  is  left  of  it.  The  dress- 
ings taken  from  a  wound  must  never  be  carried  around 
from  one  bed  to  another,  but  removed  from  the  room 
at  once.  Those  which  have  been  next  the  wound  should 
be  burned,  not  washed,  and  such  as  are  to  be  washed 
must  be  first  disinfected.  Avoid  soiling  your  own  hands 
with  dressings.  Always  have  a  basin  in  which  to  carry 
away  the  old  ones,  and  do  not  use  fingers  where  forceps 
will  do  as  well.  Do  not  go  from  one  case  to  another 
without  washing  the  hands  in  a  disinfecting  solution. 
Protect  with  a  bit  of  plaster  any  place  where  the  skin 
is  broken,  for  you  may  get  badly  poisoned  yourself 
through  a  slight  scratch.  If  you  find  such  a  slight 
wound  in  washing  your  hands,  pour  a  few  drops  of 
glacial  acetic  acid  on  the  spot.  It  will  bite,  but  it  is  a 
good  preventive.  Too  much  emphasis  can  not  be  laid 
upon  the  necessity  for  absolute  cleanliness  in  every 
way.  Cleanliness,  in  its  broadest  sense,  is  the  best  anti- 
septic; certainly,  none  can  take  the  place  of  it.  Clean 
hands,  and  especially  finger-nails,  are  of  literally  vital 
importance.  The  organic  matter  which  finds  lodgment 
under  the  nails  is  in  the  highest  degree  dangerous,  and 
has  undoubtedly  been  the  source  of  many  cases  of 
blood-poisoning.  With  sufficient  care,  however,  an  al- 


A  TEXT-BOOK  OF  NURSING 

most  absolute  immunity  from  sepsis  can  be  secured.  It 
is  now  comparatively  rare,  and  its  occurrence  always 
reflects  severely  upon  either  surgeon  or  nurse. 

Before  beginning  a  surgical  dressing  it  is  important 
to  have  at  hand  everything  likely  to  be  needed:  it  is 
awkward  for  yourself  and  fatiguing  to  the  patient  when 
you  have  to  leave  in  the  midst  of  the  process  to  find 
something  that  has  been  forgotten.  Of  course,  when 
the  doctor  is  to  do  the  dressing  you  can  not  always  tell 
just  what  he  will  call  for,  but  the  things  that  you  know 
will  be  wanting  should  always  be  ready;  and  after  you 
have  seen  a  dressing  once  you  should  certainly  know 
how  to  prepare  for  it  again.  A  protector  for  the  bed  is 
wanted  in  every  case,  as  also  are  towels,  scissors,  pins, 
and  basins.  Of  these  last  mentioned  there  should  be 
three — one  to  receive  the  discarded  dressings,  one  con- 
taining fluid  to  wash  the  wound,  and  one  to  hold  under 
it  to  catch  the  discharges.  For  the  latter  purpose  the 
crescent-shaped  basins  are  most  convenient,  as  they  fit 
closely  to  any  part  of  the  body. 

Old  dressings  should  never  be  pulled  off  forcibly. 
If  they  stick  to  the  wound,  they  should  be  irrigated  un- 
til wet  enough  to  come  off  easily.  In  removing  adhesive 
plaster,  take  hold  of  both  ends  and  make  traction  to- 
ward the  wound  from  both  directions  evenly.  It  may 
be  well  to  apply  new  strips  of  plaster  between  the  old 
ones  before  taking  them  off,  so  that  the  wound  can  not 
be  pulled  open.  Alcohol,  ether,  or  turpentine  will  re- 
move the  traces  of  paster.  If  obliged  to  leave  a  wound 
undressed,  cover  it  with  a  guard — a  piece  of  gauze  or 
muslin  saturated  with  the  antiseptic  used.  Drain  off 
the  fluid  from  the  soiled  dressings  before  throwing 
them  into  the  waste-pail,  and  take  care  that  no  instru- 
ments go  in  with  them.  Before  fresh  dressings  are 


SURGICAL  NURSING  241 

applied  the  wound  must  be  washed  with  some  antiseptic 
solution.  Do  not  rub,  but  irrigate  very  gently  until  it 
is  quite  clean.  It  will  seldom  be  necessary  even  to 
touch  it.  Dry  around  the  edges  with  the  softest  lint. 
Very  extensive  wounds,  as  severe  burns,  are  best 
dressed  only  a  part  at  a  time.  Dry  or  absorbent  dress- 
ings are  now  largely  used,  as  moisture  is  found  to  pro- 
mote the  development  of  germs.  The  practice  of  sur- 
gery has  been  revolutionized  since  the  development  of 
the  germ  theory.  The  destruction  of  infectious  germs 
or  the  prevention  of  their  multiplication  is  the  one  end 
and  aim  of  the  antiseptic  treatment  of  to-day.  The  ex- 
clusion of  these  micro-organisms  constitutes  asepsis. 
Antiseptics  hinder  their  development  and  arrest  decom- 
position, but  do  not  necessarily  destroy  their  vitality. 
True  disinfection  is  only  secured  by  germicides.  Fresh- 
ly boiled  water  cooled  in  covered  vessels  is  used  for 
washing  or  irrigating  wounds,  and  all  dressings  are 
sterilized  by  heat.  If  this  can  be  thoroughly  done  no 
chemical  disinfectants  are  necessary,  but  a  considerable 
variety  of  these  are  still  in  use  as  precautionary  meas- 
ures. By  far  the  most  reliable  is  the  bichloride  of 
mercury,  or  corrosive  sublimate.  Carbolic  acid  is  large- 
ly employed,  and  next  in  value  is  peroxide  of  hydro- 
gen. Among  numerous  others  of  more  or  less  efficiency 
are  salicylic  and  boric  acids,  the  biniodide  of  mercury, 
creolin,  iodine,  iodoform,  thymol,  listerine,  and  the 
various  chlorides  of  lime,  soda,  zinc,  etc. 

It  is  useless  to  ,give  full  directions  for  different 
dressings,  as  each  operator  has  his  own  methods,  and 
new  ones  are  continually  coming  in  vogue;  but  every 
nurse  needs  to  be  familiar  at  least  with  the  three  first- 
named  and  most  commonly  used  germicides,  to  under- 
stand how  to  manipulate  and  prepare  them  for  use. 


242  A  TEXT-BOOK  OF  NURSING 

Bichloride  of  mercury  comes  in  the  form  of  a  coarse 
white  powder,  or  in  compressed  tablets,  and  is  soluble 
in  boiling  water  or  alcohol.  It  is  commonly  used  in 
aqueous  solution,  of  strength  varying  from  1  part  in 
1,000  to  1  in  5,000.  To  prepare  the  1-1,000  solution, 
dissolve  thirty  grains  of  the  powder,  accurately 
weighed,  in  three  and  a  half  pints  of  boiling  water;  un- 
less it  is  to  be  used  immediately  add  also  thirty  grains 
of  common  salt.  Otherwise  it  is  likely  to  decompose 
and  degenerate  into  calomel  (the  mild  chloride  of  mer- 
cury), which  has  no  value  as  a  disinfectant.  In  the 
ordinary  tablet,  it  is  combined  with  chloride  of  ammo- 
nium, 7.5  grains  of  each.  One  of  these  dissolved  in  a 
pint  of  water  makes  a  solution  of  1-1,000.  This  is  the 
strongest  used  in  surgery,  and  can  be  diluted  to  any 
required  degree.  The  bichloride  solutions  have  a  cor- 
rosive effect  upon  metals,  so  that  they  can  not  be  used 
for  the  disinfection  of  instruments,  nor  must  they  be 
poured  into  any  metallic  vessel.  Gauze,  bandages,  and 
other  materials  for  dressings  are  rendered  aseptic  by 
impregnation  with  corrosive  sublimate  after  prescribed 
methods. 

Carbolic  acid,  when  pure,  comes  in  transparent 
crystals.  In  this  form  it  is  a  powerful  caustic.  The 
strongest  aqueous  solution  ordinarily  used  is  one  part 
in  twenty.  To  prepare  this,  set  the  bottle  containing 
the  crystals  in  hot  water  until  they  liquefy.  Pour  out 
carefully  one  fluid  ounce  and  add  nineteen  of  boiling 
water.  Shake  vigorously  until  the  acid  is  in  perfect 
solution.  If  any  floating  particles  are  left  undissolved 
they  will  retain  all  the  caustic  quality  of  the  crystals. 
A  solution  of  carbolic  acid  in  olive  oil  or  glycerin  (1-10 
to  1-20)  is  sometimes  used.  Carbolic  solutions  and  all 
carbolized  dressings  should  be  kept  in  air-tight  recep- 


SURGICAL  NURSING  243 

tacles,  as  it  volatilizes  readily  and  so  loses  strength. 
Carbolic  acid  can  also  be  procured  in  compressed  tablets 
— a  very  convenient  form,  and  one  which  insures  accu- 
racy of  measurement.  They  are  both  powerful  poisons, 
and  must  be  handled  with  great  care.  Enough  may  be 
absorbed  from  the  dressing  of  a  wound  to  produce  toxic 
symptoms,  and  the  nurse  should  always  be  on  the  look- 
out for  constitutional  effects  when  any  powerful  drug 
is  used  as  an  antiseptic.  Where  carbolic  acid  is  em- 
ployed the  urine  should  be  carefully  observed,  as  one 
of  the  earliest  symptoms  of  poisoning  by  it  is  a  dark- 
green  color  of  that  excretion.  Headache,  giddiness, 
and  nausea  not  otherwise  accounted  for  are  suspicious 
indications;  great  depression  of  the  vital  powers,  with 
low  temperature  and  collapse,  may  follow. 

Poisoning  from  the  external  use  of  corrosive  sub- 
limate is  marked  by  the  same  symptoms  as  when  a  mer- 
curial is  taken  internally — salivation,  vomiting,  and 
purging,  with  abdominal  and  muscular  pains,  rapid  fail- 
ure of  strength,  collapse  and  death,  if  the  cause  is  not 
removed. 

Dangerous  constitutional  effects  have  been  known 
to  result  from  the  absorption  of  iodoform  through  a 
wound.  Such  cases  are  marked  by  great  depression, 
with  headache,  loss  of  appetite,  a  continual  taste  of 
iodoform  in  the  mouth,  cerebral  disturbances,  and 
symptoms  otherwise  like  those  of  carbolic-acid  poison- 
ing. 

With  the  peroxide  of  hydrogen,  there  is  no  danger 
of  poisoning,  and  it  does  not  injure  the  normal  tissues, 
but  it  is  liable  to  undergo  changes  which  render  it 
worthless.  The  official  three-per-cent  solution  is  the 
most  stable  that  it  has  been  found  possible  to  prepare. 
It  will  decompose  if  brought  in  contact  with  metal,  and 


244  A  TEXT-BOOK  OP  NURSING 

effervesces  actively  in  uniting  with  pus.  It  is  used  to 
determine  the  presence  or  absence  of  pus,  as  a  cleanser 
of  ulcers,  and  in  washing  out  abscess  cavities,  septic  or 
tubercular,  also  to  destroy  and  remove  the  false  mem- 
brane in  diphtheria.  For  the  latter  purpose  a  swab 
is  employed  or  a  glass  atomizer. 

To  test  its  strength,  mix  a  little  in  a  test-tube  with 
permanganate  of  potassium.  The  resulting  efferves- 
cence will  be  in  proportion  to  its  efficiency. 

Among  the  materials  most  frequently  used  for  sur- 
gical dressing  are  the  bichloride  gcfuze,  already  men- 
tioned; carbolized  gauze,  a  similar  preparation  of  un- 
bleached tarlatan  or  cheese  cloth  saturated  with  a  mix- 
ture of  carbolic  acid,  alcohol,  resin,  and  paraffin;  ab- 
sorbent cotton,  cotton  wool  from  which  all  the  oil  has 
been  extracted,  often  charged  with  some  antiseptic;  lint, 
a  very  soft,  loosely  woven  linen  with  a  nap  on  one  side, 
like  Canton  flannel.  This  should  always  be  cut — never 
torn — and  placed  with  the  smooth  side  next  the  wound. 
Oiled  silk  or  rubber  tissue  is  used  to  put  over  other 
dressings  to  keep  them  moist.  Surgeon's  gauze  comes 
all  ready  prepared  for  use  in  rolls  of  from  one  to  fifty 
yards  in  length.  Also  adhesive  plaster  of  various  kinds, 
rubber,  the  heavier  "  moleskin,"  and  that  of  zinc  oxide. 
These  come  w.ound  on  spools  in  strips  of  different 
widths. 

Sutures  of  silk,  silver  wire,  catgut,  or  silkworm  gut 
are  used  for  bringing  the  edges  of  the  wound  together 
and  holding  them  in  place. 

Ligatures  of  heavier  silk  or  catgut  are  used  for  tying 
arteries,  etc.  Both  sutures  and  ligatures  should  have 
their  strength  well  tested  before  they  are  laid  out  for 
use.  The  silk  is  rendered  aseptic  by  boiling  for  an  hour 
in  a  five-per-cent  carbolic  solution,  and  is  kept  in  a 


SURGICAL  NURSING  245 

similar  solution,  or  in  alcohol,  until  wanted.  Catgut  is 
first  immersed  in  ether,  then  boiled  in  absolute  alcohol, 
in  which  it  is  kept.  Sterilized  sutures  and  ligatures 
now  come  in  sealed  glass  tubes  ready  for  use. 

Sponges  of  fine  quality  are  much  used  in  operation 
cases,  and  they  need  to  be  treated  with  the  greatest  care. 
It  is  so  difficult  to  be  sure  of  getting  them  perfectly 
aseptic  that  they  are  always  a  source  of  anxiety  to  the 
surgeon,  and  some  operators  will  not  use  them  at  all, 
substituting  pieces  of  aseptic  gauze.  New  sponges  are 
first  to  be  thoroughly  washed  in  warm  water  until  all 
particles  of  sand  and  lime  are  removed.  They  are  then 
to  be  placed  in  a  solution  of  permanganate  of  potash, 
o  ij  to  the  gallon  of  water,  and  allowed  to  remain  in 
this  solution  two  hours.  A  solution  of  hyposulphite  of 
soda,  §  iij  to  the  gallon,  is  now  made  up,  and  to  it  is 
added  §  ij  of  hydrochloric  acid.  The  sponges  must  be 
immediately  transferred  to  this  second  solution,  and  are 
kneaded  rapidly  several  times.  If  allowed  to  remain  in 
this  second  solution  too  long  they  will  become  macer- 
ated. Finally  they  are  washed  again  in  pure  water 
until  perfectly  clean  and  free  from  odor,  and  are  then 
placed  in  a  five-per-cent  (1-20)  carbolic-acid  solution 
until  required  for  use,  or  are  preserved  dry  in  tightly 
closed  glass  jars.  They  must  not  be  put  in  a  bichloride 
solution.  Sponges  which  have  been  used  may  be  freed 
from  blood  and  coagula  by  washing  first  in  a  saturated 
solution  of  washing  soda,  and  afterward  in  pure  water. 
They  must  then  be  kept  in  the  strong  carbolic  solution 
for  at  least  fourteen  days  before  they  are  used  again, 
renewing  the  solution  once  during  that  time.  Sponges 
which  have  been  in  contact  with  pus  are,  however,  most 
safely  burned.  Sponges  for  surgical  use  are  of  two 
shapes,  flat  thin  ones  for  abdominal  work,  when  an 
17 


246  A  TEXT-BOOK  OP  NURSING 

absorbent  is  needed  in  the  cavity,  and  smaller  round 
ones  for  general  purposes. 

The  care  of  the  sponges,  dressing  materials,  and  in- 
struments used  in  operations  forms  an  important  part 
of  the  work  of  a  surgical  nurse.  She  must  acquire 
familiarity  with  the  names  of  instruments  in  order  to 
be  able  to  pass  them  without  hesitation  when  called  for, 
and  after  an  operation  she  will  usually  be  expected  to 
clean  and  return  them  to  their  cases.  This  must  be 
done  so  thoroughly  that  they  will  be  surgically — that 
is  to  say,  aseptically — clean,  all  ready  for  the  next  use; 
they  must  be  washed  carefully,  for  they  are  expensive, 
and  many  of  them  so  delicate  as  to  be  easily  ruined  by 
careless  handling.  Instruments  with  cutting  edges,  as 
knives  and  scissors,  should  be  taken  by  themselves  and 
washed  carefully  one  by  one.  Never  throw  them  in  a 
heap  together,  but  lay  them  down  so  that  they  will 
touch  nothing  to  blunt  their  fine  edges.  All  instruments 
should  be  as  far  as  practicable  disjointed,  catches  un- 
locked, and  tubes  syringed  through.  Before  putting  in- 
struments in  any  disinfectant  solution  wash  all  the 
blood  off  with  soap  and  water.  Tar  soap  is  good  for 
this  purpose.  Every  stain  must  be  removed.  Rough 
surfaces  need  to  be  scrubbed  with  a  brush.  Silver  and 
steel  may  be  polished  with  a  little  whiting  moistened 
with  alcohol.  Instruments  entirely  of  metal  may  then 
be  boiled  for  half  an  hour,  but  those  having  handles 
of  ivory  or  bone  must  not  be  put  into  hot  water,  as  it  is 
likely  to  crack  them.  After  most  thorough  washing, 
these  may  be  laid  to  soak  in  1-20  carbolic.  Finally, 
dry  each  perfectly,  especially  about  the  joints,  and  put 
away  each  in  its  own  place,  so  that  they  will  not  touch 
one  another. 

It  is  in  operative  cases  particularly  that  it  is  most 


OPERATIONS  247 

important  for  a  nurse  to  be  conversant  with  the  prin- 
ciples of  asepsis  and  antisepsis,  and  to  understand  their 
practical  application.  The  antiseptic  methods  of  treat- 
ment enable  the  surgeon  to  bring  to  successful  results 
to-day  operations  which  but  a  few  years  ago  would  have 
been  regarded  as  utterly  impossible;  and  they  necessi- 
tate at  every  step  the  intelligent,  attentive  co-operation 
of  the  nurse,  for  no  amount  of  care  or  precaution  on  the 
part  of  the  surgeon  can  counteract  the  bad  effects  of 
carelessness  on  her  part.  In  every  detail  of  preparation 
of  her  own  person,  of  the  patient,  and  all  surroundings, 
it  must  be  continually  borne  in  mind  that  nothing 
should  be  brought  near  the  scene  of  operation  which 
has  not  been  rendered  aseptically  pure.  Cleanliness  and 
surgical  cleanliness  are  two  different  conditions.  It 
is  not  enough  that  all  appliances  should  be  free  from 
foreign  matter  perceptible  to  the  eye,  not  enough  that 
they  are  spotless  and  shining,  but  they  must  also  be 
absolutely  free  from  any  infectious  particles,  and  must 
be  kept  so  from  the  beginning  to  end  of  the  opera- 
tion. 

The  nurse  who  is  to  attend  a  critical  operation 
should  not  have  been  with  any  infectious  case  for  at 
least  two  weeks  previously.  Should  a  sudden  emer- 
gency make  it  necessary  for  her  to  be  present  in  spite 
of  such  exposure,  she  must  prepare  herself  by  an  espe- 
cially thorough  carbolic  or  sublimate  bath  from  head  to 
feet.  The  hair  should  in  all  cases  have  been  recently 
washed,  and  should  be  closely  confined  under  a  well- 
fitting  muslin  cap  that  has  been  sterilized.  Of  course 
only  the  most  immaculate  clothing,  caps,  and  aprons 
are  to  be  worn  in  the  operating-room.  Before  touch- 
ing sponges,  instruments,  or  dressings,  the  nails,  hands, 
and  arms  as  high  as  the  elbow  are  to  be  first  thoroughly 


248  A  TEXT-BOOK  OF  NURSING 

scrubbed  with  soap  and  water,  as  hot  as  can  be  borne, 
by  means  of  a  stiff  nail-brush;  green  soap  is  the  best; 
this  is  then  rinsed  off  with  clean  hot  water,  and  finally 
they  are  soaked  for  at  least  two  minutes  in  some  disin- 
fectant solution,  preferably  bichloride  of  mercury, 
1-2,000.  Simply  dipping  the  hands  in  the  solution  does 
not  accomplish  the  desired  object — the  destruction  of 
every  latent  germ.  Another  method  much  in  vogue  is 
as  follows:  Thoroughly  clean  the  hands  and  arms  as 
above  described,  then,  after  rinsing  off  the  soap  with 
clean  water,  wash  them  with  alcohol.  Finally  with 
another  brush,  scrub  for  a  full  minute  with  a  1-3,000 
solution  of  bichloride  of  mercury.  The  nails  should 
always  be  cut  short. 

The  patient  to  be  operated  on  should  have  a  bath 
the  night  before,  when  sufficient  notice  is  given,  and  on 
the  morning  before  the  operation  a  thorough  enema. 
Only  light  food  should  be  taken,  and,  unless  very  feeble, 
the  patient  should  fast  entirely  for  three  hours  before 
etherization.  It  is  good  routine  practice  to  administer 
a  dose  of  brandy  or  whisky  half  an  hour  previously. 
See  that  the  patient  passes  urine  the  last  thing  before 
going  to  the  operating-room.  Have  the  hair  well 
combed  and  tightly  braided,  so  that  it  can  not  get  loose 
and  tangled.  Artificial  teeth  must  be  taken  out,  and 
all  tight  bands  loosened.  Arrange  the  clothing  so  that 
it  will  be  out  of  the  way,  well  protected,  and  easy  to 
change  afterward  if  it  should  be  necessary.  If  the 
operation  is  to  be  a  lengthy  one,  it  will  be  a  wise  pre- 
caution for  the  patient  to  wear  a  flannel  jacket,  as  cases 
of  pneumonia  have  been  known  to  result  from  pro- 
longed exposure  under  ether.  Remove  all  dressings 
from  the  part  to  be  operated  upon,  and  scrub'  it  well 
with  soap  and  water;  if  there  is  hair  about  the  part, 


OPERATIONS  249 

shave  it,  and  cover  closely  with  a  towel  wet  with  anti- 
septic solution. 

In  a  private  house  you  will  have  to  get  the  room 
ready  as  well  as  the  patient.  Have  it  thoroughly 
cleansed,  well  aired,  and  at  a  temperature  of  about  70° 
F.  for  ordinary  cases.  If  you  are  preparing  for  an  ab- 
dominal section,  the  order  will  probably  be  80°,  as  it  is 
necessary  to  have  great  warmth  where  the  intestines 
are  to  be  exposed.  There  should  be  a  long,  firm  table, 
on  which  the  patient  can  lie,  so  placed  that  a  strong 
light  falls  upon  it,  plenty  of  basins,  pails,  clean  towels, 
hot  and  cold  water,  soap  and  a  new  nail-brush,  pins, 
needles,  and  scissors.  The  doctor  will  tell  "you  what 
else  will  be  needed,  and  what  dressings  he  wishes  you 
to  prepare.  But  these  he  will  usually  provide  himself. 
All  basins  and  receptacles  for  instruments  or  dressings 
must  be  carefully  attended  to,  thorough  cleanliness  of 
both  outer  and  inner  surfaces  being  essential,  inasmuch 
as  the  operating  surgeon  may  touch  the  basin  and  imme- 
diately after  may  be  called  upon  to  introduce  his  hand 
into  the  wound.  Do  not  for  an  instant  forget  that  there 
must  not  be  the  smallest  chance  that  anything  may  be 
brought  near  the  wound  which  has  been  in  contact  with 
any  even  doubtful  surface. 

There  is  often  a  delay  after  everything  is  ready,  for 
doctors  are  not  always  prompt,  though  the  nurse  must 
be.  The  time  which  must  be  spent  in  waiting  for  them 
is  most  trying  for  both  patient  and  nurse.  The  mental 
condition  of  the  patient  is  a  matter  of  very  grave  impor- 
tance, sometimes  seriously  affecting  the  result.  The 
nurse  who  is  possessed  of  tact  and  judgment  can  do  a 
great  deal  toward  inspiring  a  serene  and  hopeful  frame 
of  mind. 

The  instruments,  and  as  far  as  possible  everything 


250  A  TEXT-BOOK  OF  NURSING 

that  is  disagreeably  suggestive,  should  be  covered.  In 
the  hospital,  the  anaesthetic  is  given  before  the  patient 
enters  the  operating  theater;  when  practicable,  the 
same  plan  will  be  followed  in  private  practice. 

At  an  operation  in  a  private  house  the  nurse  will 
be  called  upon  to  do  many  things  which  in  a  hospital 
fall  to  the  lot  of  the  junior  interne;  she  may  even  be 
called  upon  to  administer  the  anaesthetic.  This  will  be 
ether  or  chloroform,  or  a  mixture  of  alcohol,  ether,  and 
chloroform,  occasionally  nitrous  oxide  gas.  Ether  is 
poured,  two  or  three  drachms  at  a  time,  on  an  inhaler, 
made  large  enough  to  fit  over  the  mouth  and  nose,  the 
air  being  entirely  excluded.  This  may  be  made  of  a 
towel  closely  folded  over  a  paper  cone.  In  operations 
performed  by  artificial  light,  the  ether  must  be  kept  at 
a  safe  distance  from  the  gas  or  lamp,  as  it  is  inflam- 
mable. The  part  of  the  face  to  be  covered  by  the  cone 
may  be  anointed  with  vaseline,  to  prevent  irritation  of 
the  skin.  Chloroform  is  not  given  in  the  same  way,  but 
is  sprinkled  a  few  drops  at  a  time  on  a  folded  hand- 
kerchief, or  a  cone  made  for  the  purpose,  and  held  at 
a  distance  of  two  or  three  inches  from  the  patient's  face, 
which  it  must  never  be  allowed  to  touch;  a  mixture  of 
atmospheric  air  is  needed.  Vaseline  should  be  used 
as  with  ether.  The  proportion  of  chloroform  inhaled 
should  not  exceed  four  per  cent.  Chloroform  as  an 
anesthetic  is  more  agreeable  and  more  rapid  than  ether, 
and  is  less  likely  to  nauseate,  but  it  is  more  dangerous, 
as  it  has  a  powerfully  depressant  effect  upon  the  heart. 
The  head  must  be  kept  low,  arid  the  patient  should  on 
no  account  be  raised  to  a  sitting  posture  while  under 
its  influence.  The  signs  of  danger  are  a  feeble  pulse, 
a  livid  face  or  extreme  pallor,  stertorous  or  irregular 
and  gasping  respiration.  Nitrous  oxide  or  "  laughing 


OPEEATIONS  251 

gas  "  is  inhaled  through  a  mouth-piece  connected  with 
a  rubber  bag  containing  the  vapor.  The  resulting 
anaesthesia  is  of  comparatively  brief  duration.  If  you 
are  charged  with  giving  any  anaesthetic,  do  not  try  to 
do  or  see  anything  else  at  the  same  time;  the  patient 
requires  your  undivided  attention.  Keep  your  finger 
on  the  pulse  and  your  eyes  on  the  face,  and  at  the  first 
warning  indication  stop  giving  the  vapor.  No  anaes- 
thetic should  ever  be  given  except  under  the  direction 
and  in  the  presence  of  a  medical  man. 

A  properly  made  and  protected  bed  should  be  all 
ready,  to  which  the  patient  may  be  transferred  as  soon 
as  the  operation  is  over.  He  must  be  kept  warm,  and 
as  quiet  as  possible,  free  from  all  excitement,  and  should 
not  be  allowed  to  sit  up  for  any  purpose.  After  any 
operation  the  strength  needs  to  be  kept  up  by  nourish- 
ing food,  but  only  in  fluid  form,  until  the  doctor's  per- 
mission is  given  to  vary  it.  The  wound  must  be  so 
arranged  that  the  dressings  can  be  observed  without 
waking  the  patient,  and,  particularly,  during  the  first 
twenty-four  hours,  it  must  be  carefully  watched  for  sec- 
ondary haemorrhage.  If  an  operation  has  been  properly 
conducted,  the  after-care  of  a  wound  will  be  simple. 
Dressings  are  now  renewed  much  less  frequently  than 
formerly.  An  amputation  stump  or  breast  may  not  be 
disturbed  for  a  week;  a  joint  possibly  not  for  two  weeks. 
To  keep  the  patient  quiet  and  to  support  his  general 
strength  while  Nature  does  her  reparative  work,  is  all 
that  is  required. 

After  a  severe  operation  or  injury  a  complete  pros- 
tration of  the  nervous  system  not  infrequently  occurs, 
known  as  a  state  of  shock.  Loss  of  blood  and  debility 
favor  shock.  It  may  even  be  caused,  in  a  feeble  subject, 
by  sudden  strong  emotion,  The  patient  becomes  pale, 


252  A  TEXT-BOOK  OF  NURSING 

and  faint  or  trembling,  the  mind  confused  or  apathetic, 
the  surface  is  covered  with  cold  perspiration,  there  is 
often  nausea,  and  sometimes  relaxation  of  the  sphinc- 
ters, causing  involuntary  passages.  It  may  result  fatal- 
ly, the  patient  sinking  into  collapse.  Brandy  and  strong 
beef-tea  should  be  given  (by  enema,  if  the  patient  can 
not  swallow),  and  heat  applied  to  the  extremities.  It 
is  in  such  cases  that  hypodermatic  medication  is  espe- 
cially valuable.  A  hot-water  bag  over  the  heart  is  a 
powerful  stimulant.  The  efforts  to  revive  the  patient 
must  not  be  continued  until  they  excite  him,  and  he 
should  not  be  allowed  to  make  any  effort  himself. 

If  a  patient  after  a  surgical  operation  escapes  death 
from  shock  or  hemorrhage,  there  is  still  a  third  great 
danger  to  which  he  is  liable — that  of  blood-poisoning. 
This  is  now  happily  rare,  but  it  is  well  to  be  acquainted 
with  the  symptoms  of  such  forms  of  it  as  may  be  en- 
countered if  aseptic  precautions  are  not  thoroughly 
taken. 

Erysipelas  is  most  contagious,  and  any  patient  devel- 
oping symptoms  of  it  must  be  promptly  isolated.  It  is 
most  frequent  in  lacerated  wounds,  and  in  those  of  the 
head  and  hands  is  rarely  of  other  than  traumatic  or'gin. 
The  secretions  of  the  wound  are  diminished,  and  its 
edges  become  red  and  swollen.  In  a  day  or  two  a  blush 
appears  about  it,  of  a  uniform  red  color,  disappearing 
on  pressure.  There  will  be  a  high  temperature,  a  quick 
pulse,  headache,  nausea,  and  a  coated  tongue.  The  dis- 
ease may  terminate  favorably  in  from  ten  to  fourteen 
days,  but  is  often  fatal. 

Pyaemia  is  usually  initiated  with  a  chill,  accompa- 
nied by  a  high  temperature,  and  followed  by  profuse 
perspiration.  The  secretions  from  the  wound  are  ar- 
rested, the  pulse  is  fast  and  feeble,  and  the  expression 


OPERATIONS  253 

of  the  face  is  anxious.  Abscesses  are  liable  to  form 
in  parts  of  the  body  distant  from  the  wound,  especially 
in  the  joints.  The  chills  may  recur  at  intervals  of  from 
eight  to  twenty-four  hours,  but  there  is  the  greatest  ir- 
regularity in  their  manifestations.  The  disease  is 
usually  fatal  in  from  four  to  twelve  days.  Curative 
measures  amount  to  little.  Try  to  maintain  the  pa- 
tient's strength,  and  to  keep  the  fever  down.  Free  ven- 
tilation and  perfect  cleanliness  are  of  the  utmost  im- 
portance, the  disease  being  most  often  occasioned  by 
fault  in  this  direction. 

Septicasmia  is  a  rather  less  dangerous  form  of  blood- 
poisoning  than  the  preceding.  It  occurs  without  the 
repeated  chills,  is  characterized  by  a  high  but  more 
regular  fever,  and  a  general  typhoid  condition.  There 
is  more  probability  of  a  favorable  termination.  In  gen- 
eral the  difference  between  pyaemia  and  septicaemia  may 
be  thus  defined:  The  latter  is  a  local,  the  former  a  gen- 
eral, expression  of  blood-poisoning  from  an  infected 
wound. 

Tetanus  is  a  usually  fatal  complication,  more  often 
following  slight  wounds  than  severe  ones.  It  may  fol- 
low exposure  of  the  wound  to  cold.  It  is  marked  by  a 
certain  muscular  rigidity,  which  sets  in  abruptly,  be- 
ginning with  the  muscles  of  the  throat  and  jaw,  and 
gradually  extending  until  the  whole  body  is  in  continu- 
ous convulsions.  It  is  important  that  the  symptoms  be 
recognized  early. 

In  addition  to  these  general  remarks,  it  may  be  well 
to  follow  in  detail  the  conduct  of  the  nurse  before,  dur- 
ing, and  after  a  capital  operation.  We  will  take  as  an 
example  a  case  of  laparotomy  or  abdominal  section,  as 
here,  perhaps  more  than  anywhere  else,  antiseptic  pre- 
cautions down  to  the  veriest  minutiae  are  vital  in  their 


254  A  TEXT-BOOK  OF  NURSING 

importance.  The  room  must  first  be  prepared  for  the 
scene  of  operation,  and  this  is  often,  especially  when  it 
must  take  place  in  a  private  house,  left  entirely  to  the 
nurse.  The  room  should  be  cleaned  the  day  before,  that 
it  may  have  time  to  be  well  aired.  The  carpet  and  cur- 
tains, all  drapery  and  superfluous  furnishings,  should 
be  removed,  the  floor  scrubbed,  the  wood-work,  and,  if 
practicable,  the  walls  also,  washed  with  a  solution  of 
bichloride,  1-2,000.  It  is  indispensable  that  a  room  be 
selected  which  can  be  well  lighted  and  ventilated.  The 
first  requisite  is  a  firm,  strong,  narrow  table,  upon  which 
the  patient  will  lie  during  the  operation.  This  must 
stand  where  the  light  is  best,  and  so  as  to  be  accessible 
from  every  side.  Cover  it  with  a  thick  blanket  or  quilt, 
a  rubber  cloth,  and  over  both  a  clean  sheet,  all  so  tucked 
in  that  no  portion  will  be  left  hanging  over  the  edge. 
A  thin  pillow  with  a  rubber  case  under  the  muslin  one 
will  also  be  needed,  and  a  couple  of  light  blankets  with 
a  second  rubber  sheet  to  cover  the  patient.  On  a  smaller 
table  place  dishes  of  glass,  china,  or  new  agate-ware  to 
receive  the  instruments.  A  third  table  may  be  needed 
for  dressings,  ether,  towels,  etc.,  and  a  wash-stand  with 
hot  and  cold  water,  soap,  nail-brush,  and  towels  for  the 
use  of  the  surgeon.  Not  less  than  three  dozen  sterilized 
towels  will  be  required,  and  three  pails  or  bowls  for 
washing  the  sponges — one  to  contain  clear  water,  one 
for  the  warm  antiseptic  solution,  and  one  for  the  clean 
hot  solution  in  which  sponges  and  towels  are  to  be 
wrung  out  when  called  for.  A  basin  to  receive  these 
after  use  will  be  wanted,  and  all  these  things  must  be 
aseptically  clean  inside  and  out.  The  antiseptic  solu- 
tion may  be  distinguished  from  the  others,  if  desired, 
by  adding  a  few  drops  of  eosin,  which  will  give  it  a 
pinkish  color.  The  sponges,  and  usually  the  dressings, 


OPERATIONS  255 

will  be  provided  by  the  surgeon — at  least  he  will  give 
explicit  directions  about  them.  A  broad  flannel  or  mus- 
lin binder,  or  a  Scultetus  bandage,  which  is  preferred 
by  some  operators,  should  be  in  readiness.  The  bed  to 
which  the  patient  is  to  be  transferred  after  the  opera- 
tion is  to  be  made  and  protected  in  the  same  way  as  for 
a  confinement  case,  tightly  pinned,  so  that  it  can  not 
work  into  wrinkles,  as  it  will  be  some  time  before  it  can 
be  renewed. 

On  the  evening  preceding  the  day  of  operation  the 
patient  is  given  a  special  bath  and  the  hair  about  the 
pubic  region  is  shaved,  care  being  taken  not  to  cut  the 
skin.  A  towel  soaked  in  a  soap  solution  (soft  soap  forty 
per  cent  to  water  sixty  per  cent)  is  placed  upon  the 
abdomen,  coming  well  down  over  the  pubes  and  held  in 
place  by  a  few  turns  of  a  roller  bandage.  Some  prefer 
a  moist  bichloride  dressing.  This  remains  on  all  night. 
In  the  morning  a  thorough  enema  is  given,  and  a  speci- 
men of  the  urine  is  saved  for  examination.  The  soap 
towel  is  then  removed,  and  the  abdomen  is  washed  with 
alcohol  to  take  off  all  the  soap.  Another  towel,  which 
has  been  soaked  in  1-1,000  bichloride  solution,  and 
wrung  fairly  dry,  is  now  placed  upon  the  abdomen,  and 
secured  like  the  other  by  a  bandage.  The  patient  is  car- 
ried to  the  operating-table  with  this  in  place;  it  is  not 
removed  until  the  last  moment.  Just  before  etheriza- 
tion the  patient  must  be  catheterized,  no  matter  how 
recently  urine  has  been  passed. 

The  nurse  enters  the  operating-room  with  surgically 
clean  hands  and  apron,  a  gown  with  short  sleeves  en- 
tirely covering  the  clothing.  Some  surgeons  wish  the 
nurse  also  to  wear  rubber  gloves.  Once  there,  her  busi- 
ness is  to  wait  on  the  doctor,  to  keep  out  of  the  way, 
and  to  watch  every  instant  to  see  that  nothing  is  handed 


256  A  TEXT-BOOK  OP  NURSING 

to  him  which  has  touched  any  doubtful  surface.  Should 
you  rest  your  own  hand  on  the  table,  wash  it  again — 
not  merely  dip  it — in  the  antiseptic  solution.  Should 
a  sponge  or  a  towel  chance  to  fall  on  the  floor,  lay  it 
aside,  and  on  no  account  use  it  again.  And  remember 
that,  whatever  your  interest  in  the  proceedings,  you  are 
present  not  as  spectator  but  as  assistant,  and  keep  on 
the  lookout,  not  so  much  to  see  what  the  surgeon  is 
doing,  as  what  he  is  likely  to  want  next.  A  second 
nurse  will  wash  the  sponges,  if  these  are  used,  first  in 
plain  water  to  rinse  out  the  blood,  then  in  the  warm 
antiseptic  solution.  Finally  they  are  dipped  in  hot  an- 
tiseptic, and  squeezed  as  dry  as  possible  before  they  are 
handed  to  the  surgeon.  No  one  detail  is  more  impor- 
tant in  these  cases  than  the  counting  of  the  sponges. 
Count  them  carefully  before  the  operation  begins,  and 
make  a  written  memorandum  of  their  number.  Do  not 
trust  your  memory.  Neglect  of  this  precaution  has 
caused  more  than  one  death.  You  will  be  expected  to 
account  for  every  one,  and  if  any  are  missing  you  must 
notify  the  surgeon  before  the  abdominal  wound  is 
closed.  The  operation  having  been  completed,  and  the 
dressings,  which  must  be  aseptic  beyond  suspicion,  hav- 
ing been  applied,  the  patient  is  put  to  bed  and  the  room 
cleared  as  speedily  as  possible  of  all  traces  of  the  opera- 
tion. Hot-water  bottles,  well  protected,  must  be  in  readi- 
ness, and  stimulants  at  hand.  The  shock  is  great  in 
laparotomy  from  the  number  of  nerve  centers  involved. 
It  is  better  not  to  place  the  pillow  under  the  pa- 
tient's head  until  the  effects  of  the  ether  have  worn  off. 
If  there  is  vomiting,  the'  abdomen  should  be  gently 
supported  by  a  hand  on  each  side  of  the  wound,  to  avoid 
any  strain  upon  the  sutures.  If  the  vomiting  is  per- 
sistent, the  application  of  ice-cold  cloths  to  the  throat 


OPERATIONS  257 

will  frequently  control  it.  It  is  important  to  distin- 
guish the  ether  vomiting  after  laparotomy  from  the 
vomiting  of  early  developing  peritonitis.  In  the  for- 
mer, which  occurs  soon  after  the  operation,  everything 
is  rejected  as  soon  as  swallowed,  and  it  stops  if  the 
stomach  is  empty,  while  with  acute  peritonitis,  the  pa- 
tient may  take  nourishment  for  hours,  and  then  sud- 
denly throw  up  a  large  quantity  of  greenish  or  yellowish 
fluid  having  a  sour  smell.  Peritonitis  usually  develops 
from  twelve  to  forty-eight  hours  after  the  operation. 

Sometimes  medicine  will  be  ordered  which  it  is  very 
important  to  have  retained.  The  simple  procedure  of 
cold  applications  to  the  throat  above  mentioned  will 
often  prevent  its  rejection,  and  it  will  add  to  their  good 
effect  if  immediately  after  the  administration  of  the 
dose  a  few  drops  of  ice-water  are  forcibly  sprinkled  on 
the  patient's  face.  The  patient  must  not  be  allowed  to 
overload  her  stomach  with  ice-water,  however  much  she 
may  desire  it.  This  is  one  of  the  few  cases  in  which 
water  is  withheld  as  much  as  possible.  Very  hot  water 
will  allay  the  thirst  better  than  ice-water,  and  does  not 
leave  the  mouth  in  such  a  parched  condition,  nor  is 
there  the  same  danger  that  the  patient  will  desire  to 
drink  too  much  of  it. 

During  the  first  twenty-four  hours  it  is  necessary  to 
watch  carefully  for  any  symptoms  of  hasmorrhage.  The 
same  symptoms  present  here  as  in  cases  of  haemorrhage 
elsewhere.  Should  the  nurse  suspect  it,  she  should  re- 
move the  pillow,  slightly  elevate  the  foot  of  the  bed, 
apply  hot  water  bottles  to  the  extremities,  having  noti- 
fied the  surgeon  as  soon  as  the  condition  is  recognized. 

The  urine  should  be  drawn,  unless  otherwise  in- 
structed, every  six  hours  for  the  first  forty-eight  hours; 
after  this  the  patient  may  pass  her  own  urine,  care 


258  A  TEXT-BOOK  OP  NURSING 

being  taken  to  disturb  her  as  little  as  possible  with  the 
bed-pan.  The  urine  must  be  measured,  carefully  ob- 
served, and  a  specimen  saved  for  examination.  It  is 
also  important  to  note  whether  or  not  the  bowels  move, 
and  the  character  of  the  defecations,  paralysis  of  the 
intestines  being  one  of  the  possible  complications  to 
be  looked  out  for. 

The  most  full  and  accurate  bedside  notes  should  be 
kept,  recording  every  change  in  the  patient's  condition. 
The  temperature,  pulse,  and  respiration  are  usually 
taken  every  four  hours  for  the  first  few  days;  however, 
the  nurse  should  be  able  by  touching  the  patient  to 
note  any  marked  variation  from  the  temperature  last 
taken,  and,  if  necessary,  take  it  again  at  once.  The 
nourishment,  of  course,  must  be  such  as  ordered  by  the 
surgeon. 

Eectal  nourishment  and  medication  may  be  neces- 
sary, and  must  be  administered  with  the  greatest  care. 
Sometimes  the  patient  will  be  nourished  entirely  by  rec- 
tum for  several  days  following  the  operation,  with  a 
view  to  giving  the  stomach  a  complete  rest.  Tympa- 
nites, if  it  develops,  may  be  relieved  by  the  introduction 
into  the  rectum  of  a  tube  through  which  the  gas  may 
escape. 

When  permission  is  given  for  the  patient  to  be 
turned  on  her  side,  the  nurse  must  see  that  the  whole 
body  is  turned  at  once,  and  very  gently,  so  that  no  twist 
or  strain  will  come  upon  the  wound.  She  must  never 
be  turned  until  the  surgeon  has  given  distinct  permis- 
sion. When  the  time  comes  for  the  stitches  to  be  re- 
moved, the  same  antiseptic  precautions  must  be  ob- 
served as  when  they  were  put  in — hands,  instruments, 
and  fresh  dressings  all  sterilized  with  the  same  care 
as  in  the  first  place.  The  patient  will  probably  not  be 


OPERATIONS  259 

taken  out  of  bed,  but  may  be  protected  by  means  of  rub- 
ber sheets  above  and  below  the  bandage.  Over  these 
must  be  spread  towels  wrung  out  in  bichloride  of  mer- 
cury, 1-1,000.  The  instruments  must  be  perfectly 
aseptic,  and  handed  to  the  surgeon  in  a  dish  containing 
carbolic  acid,  1-30. 

The  nurse  who  watches  a  laparotomy  case  shares  a 
great  responsibility,  and  the  recovery  of  the  patient  de- 
pends to  a  very  great  extent  upon  her  ability  and  faith- 
fulness. She  can  in  many  ways  make  the  patient  more 
comfortable,  but  she  must  often  seem  cruel  to  be  truly 
kind,  and  in  no  case  is  scrupulous  fidelity  to  orders  more 
obligatory. 

"The  hardest  duty  bravely  performed  soon  becomes  a  habit 
and  tends  in  due  time  to  transform  itself  into  a  pleasure." — 0.  W. 
Holmes. 


CHAPTEK   XV 

"  A  traveler  between  life  and  death, 
The  reason  firm,  the  temperate  will, 
Endurance,  foresight,  strength,  and  skill, 
A  perfect  woman,  nobly  planned 
To  warn,  to  comfort,  and  command." 

Wordsworth. 

A  LARGE  proportion  of  the  cases  coining  under  the 
care  of  a  nurse  are  those  of  disorders  of  the  female  re- 
productive organism,  classed  as  gynaecological.  These 
are  sadly  common,  various,  and  often  complicated. 
Many  of  them  might  be  prevented  by  greater  general 
knowledge  and  attention  to  the  hygiene  of  these  or- 
gans. Happily  ignorance  of  her  own  anatomy  is  no 
longer  regarded  as  essential  to  a  woman's  refinement, 
and  it  becomes  every  nurse  at  least  to  understand  some- 
thing of  the  anatomy  of  the  genital  organs,  external 
and  internal,  their  physiology  and  function,  and  the 
normal  processes  of  menstruation,  ovulation,  and 
fecundation. 

In  pathological  conditions,  the  first  important  thing 
for  the  nurse  to  understand  is  the  method  of  physical 
examination  of  the  pelvic  organs,  and  what  assistance 
the  physician  may  require.  For  a  merely  digital  exami- 
nation, little  will  be  needed  beyond  your  presence  and 
attention  to  wait  upon  the  doctor  as  he  may  desire,  and 
the  necessary  provision  for  scrubbing  and  disinfecting 
the  hands.  Never  leave  a  doctor  alone  with  a  gyna?co- 
260 


GYN^COLOGY  261 

logical  patient  except  at  his  own  request.  If  you  have 
opportunity  to  prepare  the  patient  for  examination, 
the  important  thing  is  to  see  that  the  rectum  and 
bladder  are  empty  and  the  external  genitals  clean. 

An  instrumental  examination  may  be  made  with  the 
patient  in  the  dorsal,  knee-chest,  or  lateral  position. 
Getting  the  patient  properly  posed  is  the  duty  of  the 
nurse,  and  requires  some  practice. 

In  the  dorsal  position,  the  patient  lies  flat  on  her 
back,  with  her  knees  elevated.  The  knee-chest  position 
is  the  exact  reverse,  hips  elevated,  weight  resting  on  the 
knees,  the  chest  flat  against  the  table,  not  supported  by 
the  elbows.  The  third  and  most  common  is  known  as 
the  Sims  position.  The  patient  lies  on  the  left  side, 
with  the  left  buttock  on  the  extreme  left  corner  of  the 
table,  the  left  arm  behind  her,  and  the  knees  drawn  up, 
the  right  above  the  left.  The  hand  and  right  arm  come 
well  to  the  right  side  of  the  table,  the  right  shoulder  as 
much  depressed  as  possible.  This  attitude,  with  the  aid 
of  the  Sims  speculum,  gives  the  most  complete  view  of 
the  vagina  and  uterus,  and  is  the  best  suited  for  opera- 
tions on  the  cervix  and  anterior  vaginal  wall.  The 
cylindrical  and  the  bivalve  specula  are  more  commonly 
used  with  the  patient  in  the  dorsal  decubitus.  What- 
ever position  is  taken,  the  patient  should  be  protected 
from  any  unnecessary  exposure.  A  sheet  placed  across 
the  patient  with  a  corner  tucked  under  each  foot,  the 
opposite  corners  under  both  shoulders,  the  clothing 
well  up  above  the  waist,  will  leave  the  patient  entirely 
protected  while  waiting.  When  the  physician  is  ready, 
the  curtain  formed  by  the  sheet  covering  the  vulva  may 
be  raised,  and  that  covering  the  abdomen  may  be  pushed 
down.  Under  no  circumstances  will  a  nurse  leave  a 
patient  uncovered  until  the  moment  for  examination 
18 


202  A  TEXT-BOOK  OF  NURSING 

arrives.  In  placing  a  subject  in  the  dorsal  position,  the 
nurse  should  herself  raise  the  knees  to  avoid  any  strain 
on  the  part  of  the  patient,  and  for  the  same  reason 
should  not  let  her  rise  from  it  without  first  turning 
on  the  side. 

The  speculum  is  prepared  for  use  by  boiling,  in 
order  to  sterilize  it.  It  is  then  lubricated  either  by  a 
little  oil  on  the  outer  surface,  or  by  dipping  it  in  a  one- 
per-cent  solution  of  lysol,  a  combination  of  carbolic 
acid  and  green  soap.  This  is  excellent  for  the  doctor's 
hands  also,  as  it  disinfects  as  well  as  lubricates.  The 
Sims  speculum  must  be  held  in  position  by  the  nurse. 
The  usual  way  of  doing  this  is  to  stand  behind  the  pa- 
tient, facing  the  operator.  Stand  firm  on  both  feet  in 
an  attitude  that  you  can  maintain  steadily  for  a  long 
time  if  necessary.  Pass  the  left  arm  over  the  patient's 
hips,  and  with  the  left  hand  raise  the  right  buttock, 
and,  if  desired,  separate  the  labia.  The  right  arm  may 
rest  on  your  own  hip  to  steady  it,  while  the  right  hand 
retains  the  speculum  in  the  exact  position,  and  with  the 
same  degree  of  tension,  in  which  it  is  handed  to  you. 
Other  instruments  in  use  for  these  cases  are  the  de- 
pressor, sound,  probe,  tenaculum,  curette,  volsella  for- 
ceps, uterine  dressing  forceps,  applicator,  cotton  hold- 
ers, dilators,  and  pessaries,  with  all  of  which  you  want 
to  be  familiar.  Dilators  are  used  for  stretching  the  cer- 
vical canal,  pessaries  to  hold  in  position  a  displaced 
uterus.  If  you  should  be  directed  to  remove  a  pessary, 
remember  that  it  must  first  be  turned  round  so  that  its 
long  axis  will  be  coincident  with  that  of  the  vagina. 
Various  tampons  and  other  local  dressings  are  com- 
monly employed  in  the  treatment  of  uterine  cases,  for 
the  preparation  of  which  each  doctor  will  give  his  own 
directions.  The  ordinary  tampon  is  made  by  cutting 


GYNAECOLOGY  263 

a  strip  of  absorbent  cotton  about  three  inches  wide, 
and  rolling  it  up,  not  too  tightly,  until  it  has  a  diameter 
of  about  an  inch  and  a  half.  Tie  a  piece  of  twine  or 
stout  thread  firmly  about  the  middle  of  this,  leaving 
an  end  of  at  least  six  inches  hanging,  for  convenience 
in  removal.  These  are  used  to  keep  the  parts  in  proper 
position,  and  to  apply  medication.  The  "butterfly" 
tampon  is  a  thin,  flat  piece  of  cotton  with  a  string 
similarly  tied  about  the  middle.  The  "  kite-tail "  tam- 
pon is  a  series  of  bunches  of  cotton  tied  at  intervals 
of  two  or  three  inches  along  one  string.  This  form  is 
much  used  in  case  of  uterine  haemorrhage,  and  should 
be  at  hand  when  there  is  danger  of  such,  or  strips  of 
sterilized  gauze  for  packing,  nine  inches  wide  by  about 
seven  yards  long. 

When  a  uterine  examination  is  to  be  made,  the 
tampons  should  be  prepared  and  sterilized  beforehand. 
Applicators  have  bits  of  cotton  twisted  tightly  on  their 
tips,  and  little  balls  or  squares  of  sterilized  cotton  will 
also  be  wanted  to  swab  out  the  vagina. 

Vaginal  medication  is  also  applied  by  means  of  sup- 
positories and  douches.  The  latter  is  a  mode  of  treat- 
ment which  the  nurse  will  most  frequently  have  to  give. 
The  douche  may  be  either  medicated  or  of  pure  water, 
as  directed.  The  latter,  when  tepid,  is  simply  for  clean- 
liness, but  the  hot  douche  has  a  distinct  therapeutic 
effect  on  congested  or  inflamed  pelvic  tissues.  At  first 
the  congestion  is  increased,  but  a  continued  application 
of  the  hot  water  causes  a  secondary  and  more  or  less 
lasting  contraction  of  the  blood-vessels.  Thus  it  is  an 
excellent  haemostatic  in  all  forms  of  capillary  haemor- 
rhage. It  also  induces  uterine  contractions,  and  acts 
to  a  certain  extent  as  a  local  anodyne.  Hot  douches 
should  be  of  112°  to  118°  F.,  and  are  usually  ordered 


264  A  TEXT-BOOK  OF  NURSING 

as  prolonged  douches,  from  two  to  four  quarts  being 
given.  The  patient  should  lie  on  the  back,  with  the 
hips  elevated  until  they  are  several  inches  higher  than 
the  shoulders.  A  douche  taken  sitting  or  standing  is 
of  very  limited  utility.  A  bed-pan  with  an  overflow  pipe 
is  needed.  The  fountain  syringe  is  now  chiefly  used, 
as  most  doctors  consider  the  steady  flow  under  low  pres- 
sure as  preferable  to  the  intermittent  action  of  the 
Davidson.  It  should  be  suspended  from  a  considerable 
height,  to  give  good  force  to  the  flow.  The  air  must 
be  expelled  by  starting  the  flow  of  the  fluid,  and  then 
pinching  the  tube  until  after  the  nozzle  is  inserted.  A 
thoroughly  boiled  glass  nozzle  of  the  syringe  is  used, 
and  should  be  well  introduced,  that  the  hot  water 
may  come  in  direct  contact  with  the  highest  portions 
of  the  vagina.  It  should  be  carefully  slid  along  the 
posterior  vaginal  wall  until  it  has  reached  a  point  be- 
hind the  cervix,  before  the  water  is  injected.  Any 
medication  ordered  should  be  included  in  the  last 
quart.  The  tube  should  not  be  perforated  at  the  im- 
mediate extremity,  as  there  is  danger  of  injecting  the 
fluid  into  the  cavity  of  the  uterus,  and  doing  serious 
harm,  especially  after  confinement  or  miscarriage, 
when  the  mouth  of  the  uterus  remains  open.  In  no 
case  leave  the  patient  alone  with  a  fountain  syringe  in 
operation. 

Cases  of  miscarriage  often  require  careful  nursing 
to  prevent  permanent  ill  effects.  The  first  indication 
of  an  approaching  abortion  is  haemorrhage  from  the 
uterus,  generally  accompanied  by  pain.  The  patient 
should  at  once  be  put  to  bed,  as  the  threatened  mis- 
carriage may  in  some  cases  be  averted  by  rest  and  quiet. 
If  this  can  not  be  done,  care  must  be  taken  that  the 
placenta  and  its  membranes,  the  secundines,  are  all 


GYNAECOLOGY  265 

expelled  as  well  as  the  foetus,  as  their  retention  may  oc- 
casion dangerous  haemorrhage  or  blood-poisoning.  The 
patient  should  have  as  much  care  after  a  miscarriage 
as  after  labor  at  full  term,  being  allowed  in  no  way  to 
exert  herself.  It  is  a  great  mistake  to  regard  it  as  of 
slight  importance;  the  loss  of  blood  is  often  excessive, 
and  the  shock  to  the  nervous  system  is  greater  than 
that  produced  by  regular  labor.  The  one  is  a  natural, 
the  other  a  pathological,  process.  A  season  of  perfect 
rest  is  necessary  to  allow  the  uterus  to  return  to  its 
natural  state.  Miscarriage  is  more  common  among  mul- 
tiparae,  women  who  have  borne  children,  than  among 
primiparae,  those  who  bear  for  the  first  time.  After 
it  has  occurred  a  few  times  a  predisposition  to  it 
exists,  and  it  becomes  difficult  to  carry  a  child  to  full 
term. 

The  most  common  gynaecological  operations  are 
those  for  lacerations  of  the  cervix  or  the  perinaeum, 
both  injuries  consequent  upon  childbirth,  and  for 
curettement,  scraping.  The  same  general  rules  apply 
in  all  minor  operations.  In  the  preparation  of  the 
patient  the  previous  condition  of  the  bowels  and  the 
character  of  any  vaginal  discharge  must  be  carefully 
noted  and  reported.  At  least  six  hours  previous  to 
operation  series  of  enemata  should  be  administered 
until  the  water  returns  clean,  that  the  rectum  may  be 
emptied  and  become  quiet.  The  patient  should  be  given 
a  thorough  bath  and  an  antiseptic  vaginal  douche, 
1-5,000  bichloride  of  mercury  being  commonly  ordered. 
For  perineal  operations,  shave  the  parts  and  apply  to 
the  vulva  a  bichloride  compress  1-5,000,  frequently 
changed.  Have  a  T  bandage  ready  for  use  if  required. 
After  a  cervix  or  perineal  operation,  obtain  from  the 
surgeon  definite  directions  about  emptying  the  bladder. 


266  A  TEXT-BOOK  OF  NURSING 

Of  course  all  orders  in  regard  to  diet,  medication,  and 
position  must  be  scrupulously  carried  out.  After  an 
operation  on  the  perinaeum  it  has  been  customary  for 
the  patient's  knees  to  be  tied  together,  that  no  uncon- 
scious movement  on  her  part  may  bring  a  strain  upon 
the  stitches.  The  perineal  wound  ought  to  heal  by 
first  intention,  and  if  the  stitches  are  pulled  upon  so 
as  to  cut,  even  if  they  are  not  torn  out,  this  desirable 
result  will  be  hindered.  The  treatment  consists  of 
rest  and  the  maintenance  of  absolute  cleanliness.  The 
success  or  failure  of  the  operation  depends  here  large- 
ly upon  the  nurse,  as  a  little  careless  manipulation 
on  her  part  may  render  useless  the  best  skill  of  the 
surgeon. 

If  the  patient  is  allowed  to  pass  urine  voluntarily, 
the  sutured  parts  must  be  gently  irrigated  and  dried 
after  each  micturition.  If  the  patient  is  catheterized, 
watch  that  no  inadvertent  drop  falls  upon  the  wound. 
A  piece  of  absorbent  cotton  between  it  and  the  catheter 
will  be  found  a  great  protection.  During  defecation, 
also,  the  nurse  must  see  that  no  undue  strain  is  allowed 
upon  the  stitches.  It  may  be  necessary,  especially  if  the 
laceration  has  been  through  the  sphincter,  to  support 
the  perinaeuin  with  the  hand  during  the  passage  of 
fasces.  In  these  cases,  also,  the  rectum  must  be  washed 
out  after  each  movement.  In  all  manipulations  the 
utmost  gentleness  and  care  must  be  exercised,  and  the 
most  scrupulous  cleanliness  preserved  until  the  stitches 
are  removed,  which  will  be  in  about  nine  days. 

In  cases  of  laceration  through  the  sphincter,  and 
also  of  abdominal  section,  it  is  desirable  to  have  the  pa- 
tient under  observation  and  treatment  for  several  days 
preceding  the  operation,  and  the  diet  restricted  to  such 
articles  as  leave  but  little  solid  residue  in  the  intestinal 


GYNAECOLOGY  26Y 

canal.  By  far  the  greatest  number  of  laparotomies  are 
performed  upon  female  subjects,  and  for  the  relief  of 
conditions  peculiar  to  their  sex.  The  care  of  these 
cases  has  been  already  described. 

"  The  reaction  of  matter  on  spirit  is  something  for  which  we 
do  not  always  make  due  allowance." — J.  Eoehme. 


CHAPTER   XVI 

"May  we  reach 

That  purest  heaven,  be  to  other  souls 
The  cup  of  strength  in  some  great  agony 
Enkindle  generous  ardor,  feed  pure  love, 
Beget  the  smiles  that  have  no  cruelty, 
Be  the  sweet  presence  of  a  good  diffused, 
And  in  diffusion  ever  more  intense. 
So  shall  we  join  the  choir  invisible 
Whose  music  is  the  gladness  of  the  world." 

George  Eliot. 

IT  is  perhaps  more  often  in  obstetric  cases  than  in 
any  others  that  the  nurse  will  be  called  upon  to  assume, 
in  his  absence,  the  responsibilities  properly  belonging  to 
the  physician.  It  may  happen  that  she  will  be  obliged 
to  deliver  the  child  before  medical  aid  can  arrive,  and  a 
nurse  who  undertakes  this  branch  of  the  work  should 
at  least  know  how  to  conduct  a  normal  case  without 
direction,  for  the  lives  of  both  mother  and  child  may 
depend  upon  her  skill  and  promptness.  In  order  to  be 
prepared  for  such  an  occasion  should  it  arise,  it  is  neces- 
sary for  .her  to  possess  a  much  fuller  knowledge  of  mid- 
wifery than  she  will  ordinarily  be  called  upon  to  put 
into  practice.  The  following  instructions  need  to  be 
preceded  by  a  more  thorough  acquaintance  with  pelvic 
anatomy  and  physiology  than  can  be  given  here. 

The  development  of  an  embryo  in  the  uterus  is 
known  as  pregnancy,  or  utero-gestation.  During  this 
condition  the  uterus  becomes  enlarged,  rises  out  of  the 
268 


OBSTETRICS  269 

pelvis,  and  occupies  the  abdominal  cavity.  Other  phys- 
ical signs  are  suppression  of  the  menses,  enlargement  of 
the  breasts  and  the  presence  of  milk  in  them,  and  move- 
ments of  the  foetus.  Milk  is  sometimes  found  in  the 
breasts  as  early  as  the  second  month.  This  is  pretty 
reliable  evidence  of  pregnancy,  especially  if  it  occurs  in 
a  woman  who  has  not  borne  children.  The  mammary 
glands  are  so  intimately  connected  with  the  reproduc- 
tive organs  as  to  be  usually  classed  among  them.  Dur- 
ing pregnancy  they  become  swollen  and  tender,  the 
veins  enlarge,  and  the  circles  or  areolae  about  the  nip- 
ples become  discolored.  The  papilla  around  the  nipple 
become  prominent.  Swelling  of  the  feet  is  not  uncom- 
mon, with  enlargement  of  the  veins  of  the  legs.  When 
there  is  much  oedema  of  the  legs  the  urine  should  be 
tested  for  albumin,  and  if  it  is  found  to  be  present  in 
any  quantity  the  physician  should  be  informed.  Dur- 
ing the  last  months  of  pregnancy,  the  urine  should  be 
tested  as  often  as  once  a  week.  Bladder  disturbances 
— as  retention  or  incontinence  of  urine — are  not  un- 
common. A  leucorrhceal  discharge,  may  be  present. 
Constipation,  diarrhoea,  and  other  disturbances  of  diges- 
tion may  be  looked  for.  Nausea,  particularly  distress- 
ing in  the  morning  when  the  patient  first  assumes  the 
erect  posture,  and  thence  called  "  the  morning  sickness," 
is  common  in  the  early  stage  of  pregnancy.  There  may 
be  at  the  same  time  an  abnormal  appetite.  Salivation 
sometimes  occurs.  During  the  fifth  month  the  move- 
ments of  the  foetus  usually  begin  to  be  felt  by  the 
mother.  By  this  time  the  uterus  has  risen  above  the 
brim  of  the  pelvis,  and  the  nausea  may  be  expected 
to  subside.  Many  nervous  manifestations  may  accom- 
pany pregnancy — as  insomnia,  irritability,  neuralgia, 
headaches,  toothaches,  etc.  A  cough  is  common,  and 


270  A  TEXT-BOOK  OP  NURSING 

in  the  later  stages  dyspnoea,  arising  from  pressure  upon 
the  lungs.  None  of  all  these  symptoms  occurring  singly 
has  any  diagnostic  value,  nor  is  the  absence  of  them  to 
be  counted  as  negative  proof;  but  when  they  are  found 
together  they  afford  strong  presumptive  evidence  of 
pregnancy.  Still,  a  spurious  pregnancy  will  sometimes 
manifest  all  of  the  subjective  and  even  some  of  the  ob- 
jective symptoms.  Perhaps  the  only  positive  tests  are 
ballottement  and  auscultation  of  the  fcetal  heart.  Bal- 
lottement  consists  in  displacing  the  foetus  by  a  push  of 
the  examining  finger,  against  which  it  rebounds  with 
some  force,  and  is  recognizable  to  the  practiced  touch. 
It  may  be  performed  either  externally  or  internally. 
The  beating  of  the  fcetal  heart  will  usually  be  audible 
by  the  fifth  month  through  the  stethoscope.  It  is  very 
rapid — one  hundred  and  thirty  or  one  hundred  and 
forty  beats  per  minute — and  so  readily  distinguished 
from  the  maternal  pulse.  When  these  sounds  can  be 
clearly  heard,  there  can  be  no  doubt  of  the  presence  of 
a  living  child. 

During  its  intra-uterine  existence  the  embryo,  or 
foetus,  is  contained  in  a  sac — the  amnion — which  se- 
cretes the  watery  amniotic  fluid  in  which  the  foetus 
floats.  The  foetus  is  connected  with  the  uterine  wall  by 
the  placenta  and  the  funis,  or  umbilical  cord.  Through 
these  it  receives  its  nutriment  from  the  mother. 

At  the  end  of  nine  months  the  embryo  is  fully  de- 
veloped, and  is  expelled  from  the  uterine  cavity,  the 
process  being  known  as  labor,  or  parturition.  If  such 
expulsion  occurs  before  the  embryo  is  capable  of  main- 
taining an  independent  existence — that  is,  earlier  than 
the  seventh  month — it  is  known  as  abortion  or  miscar- 
riage; if  later  than  this  period,  but  before  the  end  of 
the  ninth  month,  it  is  called  premature  labor. 


OBSTETRICS  2T1 

The  full  duration  of  pregnancy  is  280  days,  although 
it  may  be  prolonged  to  300.  The  usual  rule  for  calcu- 
lating the  date  of  its  probable  termination  is  to  add 
nine  months  and  seven  days  to  the  date  when  menstrua- 
tion last  began.  This  is  not  always  reliable,  but  is  based 
on  the  theory  that  conception  is  most  likely  to  have 
taken  place  just  after  the  close  of  the  menstrual  period. 
The  approach  of  labor  is  heralded  by  certain  prelimi- 
nary symptoms.  During  the  last  two  weeks  the  abdo- 
men diminishes  in  size,  the  uterus  sinking  down  into 
the  pelvis.  The  pressure  upon  the  lungs  gradually  be- 
comes less,  so  that  the  difficulty  of  breathing  is  removed, 
but  there  is  increased  pressure  upon  the  bladder  and 
rectum,  occasioning  frequent  evacuations.  Uterine 
contractions  begin  to  be  felt,  and  are  finally  attended 
by  pains.  True  labor  pains  come  on  at  regular  inter- 
vals, increasing  in  intensity,  and  are  usually  first  felt 
in  the  back.  False  pains  are  chiefly  in  front,  and  are 
short  and  irregular.  They  do  not  aid  at  all  in  the 
labor,  but  usually  result  from  indigestion  or  an  over- 
loaded state  of  the  bowels.  A  dose  of  castor  oil  will 
clear  the  intestines  and  probably  relieve  false  pains,  but 
violent  purgation  may  precipitate  the  real  labor.  With 
the  coming  on  of  true  pains  there  is  often  a  discharge 
of  blood  and  mucus,  sometimes  called  the  "  show." 

There  are  three  distinct  stages  of  labor.  The  first 
stage  begins  with  the  first  true  labor  pains,  and  ends 
when  the  cervix  is  fully  dilated.  In  a  normal  case,  the 
rupture  of  the  bag  of  waters  occurs  at  the  same  time 
with  the  full  dilation  of  the  cervix.  This  bag  is  formed 
by  the  pressure  of  the  contracting  uterus  upon  the  mem- 
branes containing  the  amniotic  fluid,  and  by  the  same 
means  is  forced  through  the  cervical  canal,  thus  dilating 
it.  This  is  what  takes  place  during  a  pain.  In  the 


272  A  TEXT-BOOK  OF  NURSING 

intervals  between  the  pains,  the  uterulT  relaxes,  the  am- 
niotic  bag  becomes  less  tense,  and  the  position  of  the 
child  may  be  made  out  through  its  walls.  Unfortu- 
nately, however,  often  the  membranes  rupture  before 
the  os  is  fully  dilated,  and  then  we  have  what  is  called 
a  dry  labor.  The  elastic  bag  to  help  dilate  the  cervix 
is  gone,  and  in  its  place  the  hard  bones  of  the  fcetal 
head  make  pressure.  The  labor  then  is  apt  to  be  longer 
and  harder  for  the  mother,  and  is  attended  with  some 
danger  to  the  child. 

The  second  stage  includes  the  passage  of  the  child 
along  the  pelvic  canal,  and  is  concluded  by  its  delivery. 
After  the  membranes  have  ruptured  and  the  cervix  is 
fully  dilated,  the  uterus  contracts  directly  upon  the 
child  more  and  more  strongly,  forcing  it  toward  the  pel- 
vic outlet,  the  point  of  least  resistance.  Each  pain  is 
now  accompanied  by  a  strong  impulse  to  bear  down, 
which  aids  in  the  expulsion  of  the  foetus.  These  bear- 
ing down  pains  are  typical  of  the  second  stage. 

After  this  is  accomplished  there  still  remains  the 
third  stage,  during  which  the  uterus  contracts  upon  the 
placenta,  detaching  it  from  the  uterine  surface  and 
pushing  it  out  also.  The  expulsion  of  the  placenta 
ends  the  third  and  final  stage  of  labor,  and  the  woman 
now  enters  upon  the  puerperal  state.  The  empty  ute- 
rus contracts  into  a  firm,  hard  ball,  felt  just  above  the 
symphysis  pubis.  It  continues  for  some  little  time  to 
maintain  more  or  less  painful  contractions  known  as 
"  after-pains."  These  gradually  cease.  A  discharge 
called  the  lochia  is  set  up,  which  lasts  for  three  or  four 
weeks.  It  takes  about  six  weeks  for  the  organs  to  regain 
their  normal  size  and  condition.  The  process  is  known 
as  involution.  The  puerperal  state  is  one  of  peculiar 
liability  to  contagion.  The  interior  of  the  uterus  is 


OBSTETRICS  273 

after  delivery  in  the  condition  of  an  open  wound,  emi- 
nently fit  for  the  reception  and  development  of  septic 
germs.  For  this  reason  a  nurse  must  never  go  to  an 
obstetric  case  from  one  of  contagious  disease  of  any 
kind,  or  from  a  septic  surgical  case ;  and  the  same  anti- 
septic precautions  should  be  taken  as  in  a  surgical 
operation. 

The  average  duration  of  a  natural  labor  is  sixteen 
hours,  but  in  women  who  have  previously  borne  chil- 
dren, and  often  even  in  primiparae,  it  is  frequently 
much  less. 

It  is  during  the  first  stage  of  labor  that  the  nurse  is 
likely  to  be  summoned,  and  she  should  answer  the  call 
as  promptly  as  possible,  so  as  to  have  time  to  make  all 
necessary  preparations  for  the  birth  of  the  child  with- 
out hurry. 

Should  you  have  opportunity  for  previous  consulta- 
tion with  the  expectant  mother,  you  will  frequently  be 
asked  to  state  just  what  provision  it  is  desirable  to 
make.  The  following  list  contains  all  the  essentials, 
though  it  may  be  enlarged  and  elaborated  to  any  extent 
to  suit  the  individual  taste :  For  the  baby,  there  will  be 
needed  first  a  small  old  blanket,  a  pair  of  round-pointed 
scissors,  not  too  sharp,  to  cut  the  umbilical  cord, 
and  narrow  linen  tape  with  which  to  tie  it.  Next  a 
bottle  of  olive  oil,  a  piece  of  old  white  Castile  soap, 
some  clean  soft  bits  of  old  linen,  sterilized  gauze  and 
absorbent  cotton,  a  small  soft  sponge,  a  box  of  talcum 
powder,  not  less  than  four  dozen  cotton  diapers  in  three 
sizes,  four  strips  of  flannel  for  bands  eighteen  inches 
long  by  six  inches  wide,  four  long-sleeved  flannel  shirts, 
six  flannel  petticoats,  eight  plain  slips,  three  or  four 
soft  woolly  blankets  (preferably  knitted),  and  two 
dozen  each  of  large  and  small  nickel-plated  safety-pins. 


274  A  TEXT-BOOK  OP  NURSING 

For  the  mother  will  be  wanted  six  plain  night-gowns, 
one  or  two  flannel  wrappers  (light  and  loose),  two 
flannel  sacks,  a  rubber  sheet,  a  roll  of  antiseptic  gauze, 
ten  yards  of  stout  unbleached  muslin  for  bandages,  and 
several  dozen  sterilized  vulva  pads.  This  last  may  be 
made  of  absorbent  cotton  covered  with  antiseptic  gauze, 
aud  burned  after  use.  Two  or  three  similar  pads,  a 
yard  square,  thick  and  soft,  may  be  added  for  the  pro- 
tection of  the  bed.  These  also  should  be  sterilized. 

In  addition  to  the  above-named  articles  for  the 
mother  and  child,  }7ou  should  have  at  hand,  when  the 
critical  time  arrives,  plenty  of  clean  towels,  a  new  nail- 
brush, soap,  hot  and  cold  water,  ice,  three  basins,  a  bed- 
pan, a  fountain  syringe,  a  clean  glass  catheter,  carbol- 
ized  vaseline  or  lysol,  and  brandy.  Ergot  and  chloro- 
form, carbolic  acid,  and  bichloride  solution  are  likely 
also  to  be  needed.  It  may  be  well  to  ask  the  doctor 
whether  he  wishes  you  to  provide  these. 

When  it  is  determined  that  labor  is  actually  in  prog- 
ress, the  patient  and  the  room  -should  be  got  in  readi- 
ness. Unless  there  is  a  previous  history  of  precipitate 
delivery,  the  patient  need  not  at  once  be  put  to  bed; 
indeed,  it  is  rather  better  that  she  should  stand  or  walk 
about,  resting  occasionally  on  a  chair,  but  maintaining 
an  upright  position,  as  this  renders  the  axis  of  the 
uterus  coincident  with  that  of  the  pelvis,  and  so  favors 
the  descent  of  the  head.  The  bed  should  be  prepared 
for  her,  and  well  protected.  The  under  sheet  must  be 
put  on  tightly,  as  it  may  not  be  changed  again  for  some 
days,  and  covered  by  a  rubber  and  drawn  sheet.  Over 
these  a  second  rubber  and  drawn  sheet  should  be  placed, 
which,  after  the  labor  is  over,  can  be  removed,  leaving 
the  first  clean  and  dry  for  the  patient  to  lie  on.  Add 
to  this  the  above-described  absorbent  pad.  Sometimes 


OBSTETRICS  275 

a  cot  is  used  during  labor,  and  the  patient  is  afterward 
transferred  to  the  permanent  bed.  This  is  the  best  way 
when  practicable. 

The  patient  should  have  on  a  clean  night-dress,  and 
over  it  a  warm  wrapper,  which  can  easily  be  slipped  off 
when  she  is  ready  to  go  to  bed.  Brush  the  hair  and 
braid  it  tightly.  Give  a  thorough  enema,  and  see  that 
the  bladder  is  emptied.  It  may  be  necessary  to  use  the 
catheter,  owing  to  closure  of  the  urethra  by  the  pressure 
of  the  foetal  head,  but  usually  there  will  be  frequent  and 
voluntary  passage  of  urine.  If  the  catheter  is  used,  be 
sure  that  it  is  surgically  clean.  Wash  the  external  parts 
before  using,  and  do  not  let  it  slip  into  the  vagina. 
If  this  should  happen,  take  it  out,  wash,  and  again 
boil  it  before  introducing  it  into  the  urethra,  as  other- 
wise it  may  carry  in  enough  vaginal  mucus  to  set  up 
cystitis,  and  so  produce  a  painful  complication.  You 
will  sometimes  be  directed  to  give  at  this  time  an  anti- 
septic douche.  You  may  at  least  wash  the  external 
parts,  first  with  soap  and  water  and  then  with  a  bichlo- 
ride solution  1-4,000  or  5,000,  using  for  this  purpose 
absorbent  cotton,  which  can  be  thrown  away — not  a 
sponge  or  a  wash  cloth.  This  should  be  done  before 
each  examination  and  after  each  micturition. 

The  patient  should  be  allowed  plenty  of  digestible 
food,  but  no  stimulants,  as  they  increase  the  danger  of 
post-partum  hemorrhage.  Fluid  diet  is  to  be  preferred, 
on  account  of  the  possibility  that  chloroform  may  be 
given  later. 

The  first  stage  of  labor  occupies  from  three  to  six 
hours.  An  examination  must  be  made  early  to  discover 
the  presentation  of  the  child,  but  when  this  is  once 
clearly  made  out,  too  frequent  examinations  are  to  be 
avoided,  as  during  this  stage  they  only  irritate  without 


276  A  TEXT-BOOK  OP  NURSING 

being  of  much  use.  Before  making  any  examination 
scrub  the  hands,  especially  about  the  finger-nails,  most 
thoroughly  with  soap  and  water,  rinse  off  the  soap,  and 
soak  them  in  bichloride,  1-2,000.  The  hand  taken  di- 
rectly from  this  solution  will  need  no  further  lubrica- 
tion for  an  ordinary  examination.  Introduce  the  finger 
into  the  vagina  during  an  interval  between  pains  until 
it  reaches  the  open  mouth  of  the  uterus.  The  mem- 
branes are  then  lax,  and  the  presenting  part  of  the 
fcetus  can  be  most  easily  felt,  but  the  degree  of  dilata- 
tion of  the  os  can  only  be  accurately  ascertained  during 
a  pain,  when  the  membranes  are  pressed  against  it.  Be 
very  careful  not  to  rupture  the  membranes  before  the 
os  is  fully  dilated.  The  examination  should  occupy 
the  time  taken  up  by  a  pain,  and  part  of  the  interval 
preceding  or  following.  In  the  first  stage  these  inter- 
vals are  long.  Efforts  at  bearing  down  should  not  be 
encouraged,  as  their  only  effect  is  to  exhaust  the  pa- 
tient's strength.  There  is  often  nausea,  and  even  vom- 
iting. Cramps  in  the  limbs  are  sometimes  distressing, 
but  can  generally  be  relieved  by  straightening  and  rub- 
bing them.  Chills  are  not  of  rare  occurrence.  Neither 
of  these  is  an  alarming  indication.  The  patient  should 
be  put  to  bed  when  the  pains  change  from  the  back  to 
the  front,  before  the  membranes  are  ruptured,  if  that 
event  can  be  anticipated,  as,  if  the  body  is  upright  when 
this  occurs,  there  is  more  danger  that  the  umbilical  cord 
will  be  washed  down  in  the  gush  of  waters.  The  cloth- 
ing should  be  pinned  up  well  out  of  the  way,  and  an 
extra  sheet  spread  over  the  lower  part  of  the  person, 
or  an  unstarched  white  muslin  skirt  may  be  worn.  No 
one  should  now  be  allowed  in  the  room  but  the  neces- 
sary assistants. 

The  position  taken  may  be  on  the  back  or  the  left 


OBSTETRICS  277 

side,  as  preferred,  in  either  case  near  the  edge  of  the 
bed.  The  latter  is  the  English  mode  of  delivery.  In 
this  country  the  dorsal  decubitus  is  quite  as  usual,  and 
generally  seems  easier  for  the  patient.  It  is  thought 
that  in  primiparse  the  danger  of  tearing  the  perinaeum 
may  be  less  in  the  lateral  position.  In  general  it  may 
be  stated  that  the  erect  posture  should  be  maintained 
during  the  first  stage,  the  dorsal  until  the  head  is  on 
the  perinseum,  the  lateral  during  the  birth  of  the  child, 
and  the  dorsal  again  during  delivery  of  the  placenta. 
Very  little  exposure  is  necessary;  the  clothing  can  be 
so  arranged  as  to  cover  the  patient  and  yet  be  protected 
from  discharges. 

If  you  have  not  been  able  to  decide  with  certainty 
the  presentation  of  the  child  before  the  membranes  are 
ruptured,  it  is  important  that  you  do  so  immediately 
after,  as  there  is  a  possibility  of  correcting  a  mal-pres- 
entation  by  external  manipulation  if  it  is  discovered 
early — a  possibility  which  is  lost  after  the  child  once 
sinks  into  the  basin  of  the  pelvis. 

In  a  natural  labor  the  head  presents.  This  is  the 
largest  part  of  the  child's  body,  and  where  it  passes  the 
rest  easily  follows.  The  bones  of  the  cranium  are  soft 
and  yielding,  and  are  united  only  by  membranes,  so 
that  when  pressed  together  they  can  overlap.  There 
are  two  spaces  between  them,  known  as  the  anterior  and 
posterior  fontanelles.  By  these,  and  by  the  cranial 
sutures,  the  head  is  recognized,  as  well  as  by  its  being 
harder  and  firmer  than  any  other  part.  After  the  rup- 
ture of  the  membranes,  the  scalp  will  afford  a  rough, 
hairy  sensation,  and  the  fontanelles  can  be  distin- 
guished from  each  other.  The  anterior  is  the  larger, 
and  has  four  corners;  the  posterior  is  triangular. 

Pass  a  finger  around  the  edge  of  the  os  to  discover 
19 


278  A  TEXT-BOOK  OF  NURSING 

if  any  part  beside  the  head  has  descended.  If  the  cord 
has  prolapsed,  try  if  possible  to  replace  it  above  the 
head,  as  it  is  likely  to  be  crushed  during  the  progress  of 
labor,  cutting  off  the  child's  circulation  with  fatal 
result.  The  operation  of  returning  it  will  be  facili- 
tated by  having  the  patient  rest  on  her  knees  and  elbows. 
Remember  never  to  make  any  examination,  or  even  to 
touch  the  patient  in  the  region  of  the  genitals,  without 
first  thoroughly  washing  and  disinfecting  the  hands. 

During  the  second  stage,  examinations  must  be  more 
frequent,  to  test  the  degree  of  advancement  of  the  head. 
The  pains  will  now  be  more  severe,  the  intervals  be- 
tween them  shorter,  and  there  will  be  an  impulse  to  aid 
them  by  bearing  down.  This  need  not  be  suggested, 
as  it  will  come  of  itself  at  the  proper  time.  The  patient 
not  infrequently  drops  asleep  for  a  few  minutes  between 
the  pains.  The  only  assistance  that  can  now  be  ren- 
dered is  to  support  the  back,  and  to  give  the  patient 
something  to  pull  upon  if  she  feels  inclined.  A  sheet 
knotted  to  the  foot  of  the  bed  may  be  useful  for  this 
purpose.  As  the  head  approaches  the  perineum,  this 
support  should  be  taken  away,  and  the  bearing-down 
efforts  discouraged,  lest  it  be  too  suddenly  stretched, 
and  so  torn.  The  progress  of  the  head  through  the 
vulva  must  be  rather  restrained  than  hastened,  as  the 
more  gradual  it  is  the  less  is  the  danger  of  such  a 
perineal  rupture.  This  is  most  likely  to  occur  in  a 
primipara,  and  is  usually  in  consequence  of  the  head 
being  driven  too  far  backward,  and  too  forcibly  against 
the  perinseum.  It  may  sometimes  be  averted  by  sup- 
porting the  perineum  with  the  palm  of  the  hand,  and 
guiding  the  head  forward.  This  support  should  not 
be  continuous,  but  applied  during  the  last  two  or  three 
pains,  when  the  anterior  margin  of  the  perineum  grows 


OBSTETRICS  279 

evidently  thin.  Careful  watch  should  be  kept,  and,  as 
the  head  emerges,  it  should  be  pressed  forward  and 
slightly  upward,  so  as  to  relieve  the  strain  upon  the 
perinasum  as  much  as  possible.  The  hand  should  not 
follow  the  head,  but  be  kept  upon  the  perineum  as  it 
retracts.  If  a  tear  seems  imminent,  do  not  allow  the 
head  to  emerge  during  a  pain,  but  work  it  out  gradually 
in  an  interval  between  pains.  This  manoeuvre  is  aided 
by  making  traction  with  two  fingers  in  the  rectum.  It 
is  well  to  do  the  same  while  the  shoulders  are  passing, 
though  the  greatest  danger  is  over  when  the  head  is 
safely  born.  Look  to  see  if  the  cord  is  about  the  child's 
neck,  and,  if  so,  draw  it  gently  down  and  slip  it  over 
the  head.  If  it  can  not  be  loosened  enough  for  this,  or 
if  it  is  wound  two  or  three  times  around  the  neck,  put 
a  finger  under  one  loop  and  cut  it,  tying  both  ends. 
There  will  usually  be  plenty  of  time  for  this,  as  there 
is  apt  to  be  an  interval  of  several  minutes  before  the 
shoulders  follow  the  head.  After  that  the  perinaeum 
need  no  longer  be  supported,  and  the  hands  may  be  free 
to  receive  the  child. 

As  soon  as  it  is  born,  lay  it  down  at  right  angles  to 
the  mother,  close  enough  to  make  no  traction  on  the 
cord.  The  shock  of  exposure  to  the  air  will  generally 
excite  inspiration.  If  it  does  not,  wipe  out  the  mouth, 
to  remove  any  mucus  that  may  obstruct  it,  slap  the 
child  on  the  back,  blow  on  it,  or  sprinkle  with  cold 
water.  Do  not  cut  the  cord  until  the  child  has  cried 
or  until  no  pulsation  can  be  felt  in  it;  squeeze  out  the 
contents  to  reduce  the  bulk  as  much  as  possible,  and  tie 
it  in  two  places,  one  about  two  and  the  other  three  or 
four  inches  from  the  child's  abdomen,  and  cut  between 
the  two  with  blunt  scissors,  which  will  crush  the  vessels. 
The  end  of  the  cord  should  be  examined  after  an  hour 


280  A  TEXT-BOOK  OP  NURSING 

or  so,  and,  if  there  is  any  bleeding,  another  ligature 
should  be  applied.  The  ligature  on  the  placental  end  is 
to  keep  the  placenta  from  being  drained  of  blood,  in 
which  case  the  shrinkage  would  make  its  expulsion  less 
easy,  and,  in  case  of  twins,  might  be  fatal  to  the  second 
child.  The  child,  once  separated  from  the  mother  and 
breathing  properly,  may  be  wrapped  in  a  blanket  and 
laid  aside  in  a  safe  place  while  the  mother  receives 
attention.  Immediately  upon  the  birth  of  the  child  the 
assistant  should  have  placed  one  hand  over  the  abdo- 
men, to  secure  contraction  of  the  uterus  and  to  ascer- 
tain if  there  is  a  second  child  in  it.  It  should  be  firmly 
held  until  after  it  is  entirely  empty. 

The  expulsion  of  the  placenta  may  follow  immedi- 
ately upon  that  of  the  child,  or  after  an  interval  of  half 
an  hour  or  more.  If  after  its  separation  from  the 
uterus  it  is  detained  in  the  vagina  beyond  a  reasonable 
time,  slight  traction  upon  the  cord  will  usually  serve  to 
remove  it,  but  no  such  traction  should  be  made  while 
there  is  any  attachment  to  the  uterine  surface.  The 
uterus  may  be  recognized  as  empty  when  it  is  felt  as  a 
firm,  hard  ball  just  above  the  symphysis  pubis.  If  it 
fails  to  contract  after  the  birth  of  the  child,  press  it 
down  into  the  pelvis,  with  the  hand  over  the  fundus, 
the  thumb  resting  on  its  anterior  surface,  while  the 
fingers  are  pressed  down  behind  the  organ.  This  will 
generally  stir  up  a  pain.  If  the  placenta  is  not  then 
expelled,  repeat  the  movement  with  the  next  pain.  As 
the  placenta  slips  from  the  vulva,  it  should  be  caught 
and  twisted  round  and  round,  so  that  none  of  the  mem- 
branes will  be  left  behind.  A  vessel  should  be  at  hand 
to  receive  it.  Later  it  must  be  carefully  examined  to 
see  if  it  is  entire.  If  any  portion  is  missing,  it  must  be 
looked  out  for  until  it  is  passed,  as  it  is  a  possible 


OBSTETRICS  281 

source  of  danger  so  long  as  it  is  retained.  After  exami- 
nation, burn  or  bury  it. 

The  vulva  may  now  be  bathed  with  warm  disinfect- 
ant solution,  the  soiled  articles  removed,  and  a  binder 
pinned  firmly  about  the  abdomen.  A  straight  band 
eighteen  inches  wide  is  the  best  .shape  for  this.  It  can 
be  closely  fitted  with  pins,  and  should  come  well  below 
the  hips,  so  as  not  to  ride  up.  Sometimes  a  folded 
towel  is  put  under  it,  just  over  the  fundus  uteri,  to 
make  additional  pressure  at  this  point.  Over  the  vulva 
place  a  pad  of  absorbent  cotton,  folded  in  antiseptic 
gauze.  Some  such  dressing  as  this,  which  can  be 
burned  as  soon  as  soiled,  has  now  almost  entirely  and 
very  advantageously  superseded  the  old-fashioned  nap- 
kin. It  should  be  renewed  every  three  or  four  hours  at 
first;  every  time  it  is  changed,  and  when  the  patient 
urinates  or  defecates,  the  parts  are  to  be  carefully  irri- 
gated with  the  disinfectant  solution,  or  with  water 
which  has  been  boiled.  Before  changing  the  dressing, 
the  nurse  should  disinfect  her  hands  as  in  dressing  a 
wound,  and  take  the  same  care  to  see  that  everything 
brought  in  contact  with  the  patient  is  antiseptically 
clean. 

After  the  first  dressing  the  mother  must  be  kept 
entirely  quiet,  and  the  nurse  may  give  her  attention  to 
the  child.  No  talking  should  now  be  allowed  in  the 
room,  no  visitors,  no  excitement  of  any  kind.  Before 
leaving  the  mother,  note  the  condition  of  the  pulse, 
which  should  be  rather  slower  than  usual,  from  sixty  to 
seventy.  If  it  is  above  one  hundred,  look  out  for  some 
complication,  especially  hemorrhage. 

After  the  mother  has  rested  a  few  hours,  and  the 
child  has  been  washed  and  dressed,  it  is  well  to  put  it 
to  the  breast.  The  first  milk,  the  colostrum,  is  of  quite 


282  A  TEXT-BOOK  OP  NURSING 

different  quality  from  the  later  secretion,  and  has  a  pur- 
gative effect  upon  the  child,  clearing  the  intestines  of 
the  meconium,  a  dark  viscid  matter  with  which  they  are 
loaded  at  birth.  The  suckling  of  the  child  helps  to 
secure  contraction  of  the  uterus,  often  occasioning  quite 
severe  after-pains;  it  excites  more  abundant  secretion 
and  draws  out  the  nipple.  Indeed,  it  is  quite  as  much 
for  the  mother's  sake  as  for  the  child's  that  it  is  put  to 
the  breast  thus  promptly.  The  baby  will  not  suffer  if 
it  has  no  food  at  all  for  the  first  twenty-four  hours.  Dp 
not  accept  any  suggestions  with  regard  to  the  necessity 
of  feeding  it.  The  colostrum  is  scanty,  but  quite  suffi- 
cient for  the  need.  When  the  breasts  are  engorged, 
very  gentle  rubbing  with  warm  oil,  always  in  a  direction 
from  circumference  to  center,  will  accelerate  the  flow 
of  milk.  The  milk  does  not  appear  in  abundance  until 
about  the  third  day.  Its  secretion  may  be  delayed  till 
the  fifth  or  sixth  day.  There  is  almost  always  some 
pain  and  constitutional  disturbance  accompanying  it, 
and,  if  the  breasts  are  not  properly  relieved,  milk  fever 
and  mammary  abscess  may  ensue.  If  the  child  can  not 
empty  the  breast  sufficiently,  the  milk  should  be  drawn 
off  by  a  breast-pump.  A  good  substitute  for  a  breast- 
pump  is  a  champagne  bottle  with  a  smooth  edge;  fill  it 
with  hot  water,  let  it  stand  a  moment,  then  pour  it  out 
quickly,  oil  the  edge,  and  apply  the  mouth  of  the  bottle 
over  the  nipple.  As  the  heated  air  condenses,  the  milk 
will  be  sucked  out  into  the  bottle.  The  condensation 
may  be  increased  by  wrapping  around  the  bottle  a  towel 
wet  in  cold  water.  The  same  method  is  useful  to  draw 
out  a  retracted  nipple,  which  the  child  has  difficulty  in 
grasping.  Sunken  or  retracted  nipples  may  be  some- 
what helped  by  gently  drawing  them  out  with  the  fingers 
several  times  daily.  It  is  a  good  plan  to  manipulate 


OBSTETRICS  283 

them  in  this  way  during  the  last  two  or  three  months 
previous  to  confinement,  and  at  the  same  time  to  rub 
them  with  vaseline  or  cacao  butter,  to  render  the  skin 
soft  and  flexible.  This  treatment  will  go  far  to  prevent 
them  from  becoming  excoriated  or  fissured.  Should  this 
happen,  it  may  be  necessary  to  use  nipple  shields  at  the 
time  of  suckling.  The  nipples  must  be  kept  free  from 
pressure,  and  the  breasts  protected  by  an  extra  cover- 
ing, as  they  are  very  sensitive  to  cold.  They  need  to 
be  kept  clean,  but  it  is  not  well  to  bathe  the  nipples 
too  much,  as  it  makes  them  tender.  After  each  nurs- 
ing, sprinkle  them  liberally  with  talcum  powder  with- 
out washing  or  otherwise  drying  them,  and  they  will 
in  the  majority  of  cases  need  no  other  treatment.  Of 
course  this  must  be  washed  off  before  the  child  is  again 
put  to  the  breast,  preferably  with  a  solution  of  boracic 
acid. 

If  the  child,  for  any  reason,  is  not  to  nurse,  the 
secretion  of  milk  must  be  checked.  This  is  usually  done 
by  bandaging  the  breasts  closely,  supporting  them  by 
pads  of  cotton  at  each  side,  so  that  the  pressure  will  be 
made  evenly.  The  bowels  must  be  kept  open,  and  the 
amount  of  fluid  taken  into  the  system  limited  as  far  as 
possible.  Belladonna  is  sometimes  employed  to  help 
dry  up  the  secretion,  usually  in  the  form  of  an  unguent 
rubbed  in  gently.  Kubbing  of  the  breasts  must  always 
be  toward  the  nipple. 

The  mother  during  the  puerperal  state  requires  the 
most  careful  nursing.  She  should  be  kept  in  bed  for 
ten  days  or  two  weeks,  not  being  allowed  to  sit  up  for 
any  purpose,  or  in  any  way  to  exert  herself.  It  is  of 
the  greatest  importance  that  she  and  everything  about 
her  be  kept  clean.  She  should  have  a  thorough  sponge- 
bath  all  over  every  day,  and  the  vulva  should  be  washed 


284  A  TEXT-BOOK  OF  NURSING 

two  or  three  times  daily.  On  the  question  of  douches, 
doctors  differ.  If  you  have  no  especial  directions,  it  is 
safe  to  give  one  of  1-5,000  bichloride  or  of  boiled  water 
immediately  after  labor  and  then  no  more  unless  the 
lochia  become  offensive,  as  may  occur  after  five  or  six 
days.  There  should  be  no  odor  perceptible  on  entering 
the  room.  Have  plenty  of  fresh  air,  but  at  the  same 
time  be  careful  to  avoid  chilling  the  patient,  especially 
when  she  first  gets  up.  The  catheter  must  be  used  every 
six  or  eight  hours  if  the  bladder  can  not  be  otherwise 
emptied.  There  is  often  temporary  paralysis  of  the 
vesical  neck  following  labor.  A  laxative  or  an  emollient 
enema  should  be  given  on  the  third  day,  and  every 
second  day  thereafter  until  the  bowels  move  naturally. 
The  diet  should  be  light  and  unstimulating  for  the  first 
week;  after  that,  if  the  patient  is  progressing  favorably, 
she  may  return  to  her  usual  diet. 

One  of  the  greatest  dangers  attending  childbirth  is 
that  of  ha?morrhage.  This  may  take  place  either  be- 
fore, during,  or  soon  after  labor. 

Haemorrhage  immediately  after  delivery  is  known  as 
post-partum  haemorrhage;  occurring  two  or  three  days 
later,  it  is  called  secondary.  It  may  follow  even  a  per- 
fectly natural  labor  so  profusely  as  to  endanger  life. 
There  is  little  fear  of  it  while  the  uterus  is  firmly  con- 
tracted. If  it  is  felt  to  be  enlarging  and  relaxing,  it  is 
a  sign  of  danger,  and  every  effort  must  be  made  to  in- 
duce contractions,  which  prevent  the  escape  of  blood  by 
lessening  the  caliber  of  the  blood-vessels.  This  symp- 
tom, and  other  indications  of  haemorrhage — as  pallor, 
coldness  of  the  extremities,  feeble  pulse  and  respiration 
— must  be  watched  for,  especially  when  the  patient  is 
asleep. 

"Watch  particularly  the  lips,  as  the  mucous  mem- 


OBSTETRICS  285 

brane,  being  thinner,  shows  loss  of  blood  more  quickly 
than  the  skin.  The  blood  may  come  in  a  sudden  gush, 
or  in  a  slow  but  steady  flow,  from  the  placental  site,  and 
is  in  consequence  of  failure  of  the  uterine  muscles  to 
contract  and  close  the  blood-vessels  left  open  by  the 
separation  of  the  placenta.  The  direct  object  of  treat- 
ment is  to  induce  contractions  of  the  uterus.  Open  the 
windows  to  give  abundant  fresh  air,  elevate  the  foot 
of  the  bed,  and  make  vigorous  pressure  upon  the  uterus. 
You  may  give  ergot  if  the  uterus  is  empty,  but  never 
while  the  fcetus  or  placenta  remain  in  it.  The  impor- 
tant thing  is  to  empty  the  uterus,  and  you  should  not 
hesitate  to  introduce  the  whole  hand  in  order  to  clean 
it  out.  If  the  placenta  has  not  been  expelled,  it  must 
now  be  removed  without  delay,  but  never  try  to  extract 
it  by  pulling  upon  the  cord.  The  hand,  first  made  asep- 
tic, should  be  inserted  well  above  the  placenta,  sp  as 
to  make  sure  of  getting  the  whole  of  it.  In  the  same 
way,  you  should  sweep  out  any  clots  which  may  prevent 
the  uterus  from  contracting,  and  knead  the  organ  vig- 
orously, with  one  hand  inside  and  one  on  the  abdominal 
surface.  You  may  carry  into  the  uterus  with  the  hand 
a  lump  of  ice,  or  a  sponge  soaking  in  vinegar,  or  inject 
hot  water  (116°  F.),  but  with  all  this  allow  the  patient 
herself  to  make  absolutely  no  effort.  The  most  efficient 
way  of  controlling  the  bleeding  is  to  stuff  the  uterus 
full  of  sterilized  gauze.  This  the  nurse  can  do  at  once 
if  she  is  alone  and  can  not  leave  the  patient  to  prepare 
a  hot  douche. 

Internal  haemorrhage  during  labor  is  a  formidable 
complication,  since  there  may  be  no  escape  of  blood  ex- 
ternally. The  patient  suddenly  collapses,  and  has  a 
severe  bursting  pain  in  the  abdomen.  Labor  pains  cease 
and  the  uterus  becomes  greatly  distended.  Give  stimu- 


286  A  TEXT-BOOK  OF  NURSING 

lants  hypodermically,  and  summon  the  nearest  physi- 
cian. 

Another  peculiar  danger  to  which  this  state  is  liable 
is  that  of  puerperal  fever,  a  form  of  blood-poisoning 
most  commonly  established  within  three  or  four  days 
after  labor,  resulting  either  from  absorption  of  the  de- 
composing matter  produced  by  the  woman  herself,  or 
from  infection  brought  to  her  from  some  external 
source.  After  the  raw  surfaces  are  healed  over  and 
the  os  uteri  closed,  the  danger  is  less,  but  antiseptic 
precautions  ought  still  to  be  kept  up.  The  disease  is 
commonly  initiated  by  chills,  followed  by  high  fever, 
the  temperature  rising  to  102°,  103°,  or  even,  in  severe 
cases,  to  106°.  The  pulse  is  rapid;  the  countenance 
sunken  and  anxious;  there  is  a  sickly  odor  to  the  breath; 
usually  diarrhoea  and  vomiting;  the  lochial  discharge  is 
suppressed,  or  becomes  altered  in  character;  the  secre- 
tion of  milk  ceases.  It  is  often  complicated  with  peri- 
tonitis or  metritis — inflammation  of  the  uterus.  The 
symptoms  and  severity  are  variable,  but  it  is  always  dan- 
gerous and  highly  infectious.  The  treatment  is  prac- 
tically the  same  as  that  of  wound  infection  in  general— 
the  application  of  antiseptics  to  the  affected  surface  and 
supporting  the  general  strength.  Fresh  air,  surgical 
cleanliness,  and  faithful  antisepsis  will  prevent  its  de* 
velopment. 

Another  disease  of  the  puerperal  state,  though  not 
entirely  confined  to  it,  is  phlegmasia  dolens,  commonly 
known  as  milk-leg,  from  a  popular  but  entirely  un- 
founded notion  that  the  milk  settles  in  the  leg.  It  is 
caused  by  obstruction  of  the  femoral  vein  by  a  blood- 
clot,  and  results  most  commonly  from  exposure  or  over- 
exertion;  it  is  a  local  expression  of  septic  infection. 
The  leg  swells  and  becomes  intensely  painful,  the  skin 


OBSTETRICS  287 

white  and  tense.    There  is  often  fever  accompanying  it, 
and  sometimes  chills.     It  is  treated  by  absolute  res! 
Support  the  limb  comfortably,  keep  it  warm  by  envel 
oping  it  in  cotton  wool,  and  the  condition  may  be  ex- 
pected to  gradually  disappear,  though  it  does  not  always 
terminate  so  happily. 

Puerperal  convulsions  sometimes  occur,  technically 
termed  eclampsia.  These  are  usually  of  a  uramic  type, 
resulting  from  deficient  action  of  the  kidneys,  and  are 
very  dangerous.  On  account  of  the  premonitory  symp- 
toms, often  overlooked,  a  pregnant  woman  should  be 
under  the  care  of  a  physician  for  some  time  previous  to 
labor,  and  during  the  later  months  the  urine  should  be 
tested  for  albumin  every  ten  days.  Preventive  treat- 
ment is  most  important. 

Headache,  with  ringing  in  the  ears  and  bright 
flashes  before  the  eyes,  dyspnrea,  nausea,  puffiness  of 
the  face,  hands,  and  labia,  and  diminished  excretion  of 
urine,  are  among  the  alarming  symptoms.  Give  large 
doses  of  cream-of -tartar  water  (3ij-0j),  keep  the 
bowels  open  with  saline  laxatives,  and  try  in  every  way 
to  induce  free  perspiration.  Should  the  convulsions 
occur,  they  may  be  quieted  by  chloroform.  If  no  chloro- 
form is  at  hand,  little  can  be  done  except  to  keep  the 
patient  from  hurting  herself.  Eight  or  ten  minims  of 
Magendie  may  be  injected,  or  chloral,  gr.  xx-xxx,  may 
be  given  per  rectum.  Give  plenty  of  fresh  air,  see  that 
the  clothing  is  entirely  loose,  and  put  something  be- 
tween the  teeth  to  keep  the  tongue  from  being  bitten. 
The  patient  will  be  entirely  unconscious  during  the  at- 
tack, and  may  rouse  at  first  as  if  from  sleep,  but,  unless 
speedy  relief  is  obtained,  soon  sinks  into  fatal  stupor. 
If  oedema  of  the  lungs  suddenly  develops,  apply  dry 
cups  and  mustard  poultices. 


288  A  TEXT-BOOK  OP  NURSING 

A  form  of  insanity  may  follow  labor,  known  as  puer- 
peral mania.  It  usually  takes  the  form  of  melancholia, 
often  with  a  disposition  to  injure  the  child.  It  is  acute 
while  it  lasts,  but  rarely  permanent.  It  is  a  possibility 
against  which  the  nurse  should  always  be  on  her  guard, 
as  it  may  come  on  very  abruptly,  sometimes  even  before 
the  labor  is  ended.  Look  out  for  a  patient  who  has  been 
low-spirited  during  pregnancy. 

"  Heaven  lies  about  us  in  our  infancy. 

Our  birth  is  but  a  sleep  and  a  forgetting. 
The  soul  that  rises  with  us,  our  life's  star, 

Hath  had  elsewhere  its  setting, 
And  cometh  from  afar." 

Wordsworth. 


CHAPTER   XVII 

"Dispose  not  thyself  for  much  rest,  but  for  great  patience." 
— Thomas  a  Kempis. 

THE  care  of  an  infant  begins  with  its  separation 
from  the  mother  and  the  tying  of  the  umbilical  cord. 
Independent  circulation  and  respiration  should  now  be 
established,  and  its  existence  as  a  separate  entity  com- 
mences. The  first  thing  is  to  see  if  the  heart  is  beating 
and  the  child  is  breathing  properly.  The  shock  of  con- 
tact with  the  air  will  generally  excite  respiration,  but  if 
it  fails  to  do  so  it  must  be  artificially  stimulated.  To 
do  this,  first  wipe  out  the  mouth  and  throat  with  the 
finger  to  remove  any  accumulation  of  mucus  which 
might  obstruct  the  air  passages,  then  fan  or  blow  upon 
the  child  sharply,  sprinkle  cold  water  in  its  face,  slap  its 
back,  or,  if  these  measures  produce  no  effect,  dip  it 
alternately  into  cold  and  hot  water.  The  cold  water  is 
merely  to  produce  shock,  and  the  child  should  remain 
in  it  but  an  instant,  and  then  be  immersed  for  a  minute 
or  two  in  hot  water — not  over  110°  F.  Then  dry  and 
rub  with  flannel.  If  natural  respirations  are  still  not 
established,  they  should  be  artificially  produced — after 
Sylvester's  method — and  kept  up  as  long  as  the  heart 
beats  ever  so  faintly.  If  the  child  seems  strong  and  the 
heart-beats  are  vigorous,  Schultze's  method  of  estab- 
lishing respiration  may  be  adopted.  His  procedure  is  as 
follows:  Stand  and  grasp  the  child  so  that  your  thumbs 

289 


290  A  TEXT-BOOK  OF  NURSING 

rest  on  its  chest,  the  index-fingers  are  in  the  axillae, 
and  the  other  fingers  cross  the  back  diagonally.  Sus- 
pend the  child,  held  in  this  manner,  between  the  knees, 
its  face  to  the  front;  swing  the  child  upward  until  your 
arms  are  horizontal,  then  stop  suddenly.  As  the  child's 
head  falls  backward,  support  it  with  the  fingers  which 
rest  on  its  back.  The  legs  will  curl  forward,  as  if  the 
child  were  going  to  turn  a  somersault  backward,  and 
the  weight  of  the  body  will  be  thrown  upon  your 
thumbs,  compressing  the  thorax  and  abdomen,  and 
causing  a  forced  expiration.  Swing  the  child  back  to 
its  former  pendent  position,  and  a  deep  inspiration  will 
be  produced.  Repeat  eight  or  ten  times  at  intervals  of 
ten  or  fifteen  seconds,  then  drop  the  child  into  a  warm 
bath.  If  it  does  not  yet  breathe,  repeat  the  swinging 
process  as  before.  This  mode  of  treatment,  though  in 
some  cases  excellent,  should  not  be  tried  on  a  feeble 
infant  with  weak  action  of  the  heart.  Do  not  swing  the 
child  too  often,  and  stop  if  it  begins  to  breathe. 
Through  all  these  processes,  be  careful  not  to  let  the 
child  become  chilled.  After  every  shock  of  cold  water 
or  cold  air,  a  plunge  into  warm  water  should  be  given 
to  restore  the  vital  heat.  In  delicate  and  especially  in 
premature  infants,  although  breathing,  there  may  be 
very  low  vitality,  and  warmth  may  be  more  essential  to 
their  preservation  than  anything  else.  It  is  often  a 
matter  of  difficulty  to  keep  them  warm  enough.  A 
couveuse  or  incubating  apparatus,  in  which  a  perfectly 
even  temperature  can  be  maintained,  is  sometimes  used, 
and  the  child  is  kept  in  it  until  it  has  acquired  suffi- 
cient vigor  to  endure  the  variations  of  an  ordinary  at- 
mosphere. 

All  babies  need  at  first  a  great  deal  of  warmth. 
Through  fear  of  chilling  them,  some  physicians  prefer 


SICK  CHILDREN  291 

not  to  have  a  child  washed  for  several  hours  after  birth. 
To  remove  the  vernix  caseosa,  or  cheesy  varnish  with 
which  it  will  be  more  or  less  covered,  it  may  be  rubbed 
with  sweet  oil,  and  then  wiped  off  with  a  soft  cloth. 
For  a  feeble  child,  this  is  all  the  cleansing  of  the  body 
necessary  at  first,  except  that  in  all  cases  the  eyes  must 
be  thoroughly  washed.  For  this  purpose'  use  a  warm 
saturated  solution  of  boric  acid. 

Ordinarily,  however,  the  baby  may  be  washed  at  the 
nurse's  convenience,  while  the  mother  is  resting.  The 
bath  should  be  given  in  a  warm  place,  and  its  tempera- 
ture be  not  much  above  that  of  the  air.  An  old-fash- 
ioned way  of  testing  the  heat  of  the  water  is  by  the 
elbow,  to  which  it  should  feel  neither  cold  nor  warm. 

Take  the  feet  of  the  child  in  the  right  hand,  the 
shouders  in  the  left,  letting  the  head  rest  upon  the  arm, 
and  lower  it  very  gradually  into  the  water.  Still  sup- 
porting the  head  with  the  left  hand,  wash  it  all  over 
with  a  clean  soft  sponge,  then  lift  it  out  into  the  folds 
of  a  warm  towel.  Dry  thoroughly,  especially  about  the 
joints,  but  without  much  rubbing.  Dust  with  talcum 
powder  under  the  arms  and  between  the  legs,  and  look 
to  see  if  the  anus  and  urethra  are  open  and  the  child  in 
a  normal  condition  all  over.  Wrap  the  cord  in  dry 
salicylated  cotton  and  lay  it  on  the  left  side  of  the  body. 
Keep  it  in  place  by  a  flannel  band  about  the  abdomen, 
tight  enough  not  to  slip,  but  not  so  tight  as  to  impede 
the  child's  respiration.  All  the  garments  should  be 
warm  and  not  too  tight.  Put  one  inside  another,  and 
the  whole  on  over  the  feet  rather  than  the  head,  turn- 
ing the  child  no  more  than  is  necessary. 

From  this  time  on  the  baby  should  have  a  bath  all 
over  daily.  The  best  time  for  it  is  in  the  morning,  and 
half-way  between  two  meals.  The  temperature  of  the 


292  A  TEXT-BOOK  OP  NURSING 

room  in  which  it  is  given  should  be  not  less  than  75°, 
and  the  temperature  of  the  water  100°.  The  child 
should  not  remain  in  the  tub  more  than  five  minutes. 
Little  soap  is  needed  and  little  rubbing,  for  the  skin  is 
very  tender.  Use  talcum  powder  where  there  is  any 
suggestion  of  chafing.  Fresh,  dry  cotton  should  be 
put  on  the  cord  each  day  until  it  falls  off,  which  it  will 
do  in  about  a  week;  boric  acid  is  a  good  dressing.  It  is 
well  then  to  keep  a  compress  over  the  umbilicus  until 
it  is  depressed  and  of  the  same  color  as  the  surrounding 
skin.  The  shirt  should  be  long  enough  to  meet  the 
diapers,  to  which  it  may  be  pinned.  It  also  should  be 
of  flannel,  with  long  sleeves,  and  open  all  the  way  down 
the  front.  Over  this  a  flannel  petticoat  or  sleeveless  slip 
should  come  down  well  over  the  feet.  Socks  are  unim- 
portant while  long  dresses  are  worn,  but  the  feet  must 
be  kept  thoroughly  warm.  The  outer  garments  vary  to 
suit  the  taste,  but  everything  should  be  soft,  warm,  and 
loose.  Cotton  diapers  are  better  than  linen.  These 
should  be  changed  as  soon  as  wet,  and  never  used  again 
without  having  been  washed.  The  bowels  may  be  ex- 
pected to  move  two  or  three  times  daily.  The  meco- 
nium  ought  to  be  cleared  out  and  water  passed  during 
the  first  twenty-four  hours.  If  the  latter  fails  to  occur, 
apply  a  hot  stupe  over  the  kidneys.  The  child's  breasts 
will  sometimes  be  swollen  and  full  of  milk  for  a  few 
days  after  birth.  Do  not  rub  or  let  the  clothing  make 
any  pressure  upon  them,  and  the  condition  usually  will 
gradually  disappear  without  treatment. 

As  a  rule,  the  most  suitable  food  for  a  baby  is  its 
mother's  milk,  or,  that  failing,  the  nearest  approach  to 
it  that  can  be  made,  though  there  are  exceptional  cases 
in  which  the  mother's  milk  fails  to  agree  with  the 
child.  The  child  should  be  fed  during  the  first  three 


SICK  CHILDREN  293 

months  at  intervals  of  two  or  three  hours  regularly. 
The  intervals  may  be  longer  at  night.  In  putting  the 
child  to  the  breast,  see  that  the  nostrils  are  not  ob- 
structed; otherwise  it  can  neither  breathe  nor  suck. 
It  should  not  be  allowed  to  go  on  sucking  indefinitely 
after  it  has  had  food  enough,  or  to  suck  an  empty  feed- 
ing-bottle, its  own  fingers,  or  anything  else.  This  may 
keep  it  quiet  for  a  time,  but  ultimately  makes  matters 
worse  by  getting  its  stomach  overloaded  or  full  of  wind. 
A  baby  need  not  be  assumed  to  be  hungry  because  it 
cries,  but  something  is  the  matter  with  it,  and  it  is  the 
business  of  the  nurse  to  find  out  what.  It  does  not  cry 
unless  it  is  in  some  way  uncomfortable.  A  child  a  month 
old  should  sleep  twenty  hours  out  of  the  twenty-four 
without  being  rocked  or  carried  about.  Habits  will  be 
easily  acquired  at  this  age.  The  child  should  sleep  in 
a  crib,  and  be  taught  to  go  to  sleep  by  itself.  Let  it  lie 
on  either  side,  not  directly  on  the  back,  as  there  is  dan- 
ger in  this  position  that  the  milk  may  regurgitate  and 
get  into  the  trachea.  Do  not  have  a  strong  light  in  the 
room,  as  the  eyes  of  both  mother  and  child  are  weak. 
If  the  child  is  not  to  nurse  its  mother,  it  may  be  given 
half  a  teaspoonful  of  the  -sirup  of  rhubarb  soon  after 
birth  to  remove  the  meconium,  as  it  will  miss  the  pur- 
gative action  of  the  colostrum. 

In  the  absence  of  the  mother's  milk,  that  of  a  suit- 
able wet-nurse  is  considered  the  best  food  for  the  child, 
but  desirable  ones  are  very  difficult  to  find.  She  must 
be  a  perfectly  healthy  and  not  nervous  woman,  whose 
own  child  is  nearly  the  age  of  the  one  she  is  to  nurse. 
If  cow's  milk  is  used,  it  must  be  at  first  diluted  with 
twice  as  much  water,  and  slightly  sweetened.  Unless 
it  comes  from  thorough-bred  Jerseys,  cream  should  be 
added  to  it  and  a  little  salt.  Sugar  of  milk  is  the  best 
20 


294  A  TEXT-BOOK  OF  NURSING 

for  sweetening,  and  boiled  water  should  always  be  used 
for  diluting  the  milk.  The  proportion  of  water  may 
be  gradually  lessened,  until  after  six  months  the  milk 
may  be  given  pure.  Milk  from  a  single  cow  is  no  longer 
recommended,  as  the  average  from  a  well-cared-f or  herd 
is  more  uniform  in  quality.  Condensed  milk  is,  per- 
haps, of  more  even  quality  than  the  ordinary  dairy  prod- 
uct, but  it  is  apt  to  be  constipating.  Unless  the  milk 
is  exceptionally  pure  and  directly  obtained,  it  should  be 
Pasteurized  before  use.  This  process  consists  in  rais- 
ing the  temperature  of  the  milk  to  167°  F.,  and  so  keep- 
ing it  for  twenty  minutes.  This  practically  sterilizes 
it  without  boiling,  and  does  not  so  much  alter  its  char- 
acter. Milk  treated  in  this  way  can  be  kept  on  ice  for 
several  days.  Modified  milk  can  now  be  obtained  in 
some  places,  especially  adapted  for  children  of  different 
ages.  An  excellent  formula  is  that  known  as  Meigs's 
mixture,  consisting  of 

1  part  milk, 

2  parts  cream, 

2  "      limewater, 

3  "       sugar  water. 

The  sugar  water  is  made  by  adding  two  heaping 
tablespoonfuls  of  pure  sugar  of  milk  to  a  pint  of  water. 
Sterilize  the  entire  mixture.  Let  the  infant  nurse  di- 
rectly from  the  sterilizing  bottles,  substituting  a  clean 
rubber  nipple  for  the  cork,  and  warming  to  the  tem- 
perature of  new  milk  by  standing  the  bottle  in  hot  water 
for  a  few  minutes.  The  best  appliances  are  those  that 
can  be  most  easily  cleaned.  Graduated  bottles  save 
labor  in  the  measuring  of  food.  Use  a  plain  black  rub- 
ber nipple  fitting  over  the  neck  of  the  bottle,  with  an 
opening  large  enough  to  allow  the  milk  to  drop  rapidly 
when  inverted,  but  not  to  flow  out  in  a  stream.  When 


SICK  CHILDREN  295 

not  in  use,  let  them  lie  in  a  borax  solution,  and  keep 
the  bottles  full  of  clean  water.  Just  before  using, 
sterilize  them  both.  After  use,  rinse  first  with  cold 
water,  then  wash  with  hot  soapsuds. 

If  the  food  is  rejected,  either  the  child  is  overfed — 
a  common  source  of  trouble — or  the  food  is  in  some  way 
unsuitable.  Vomiting  by  an  infant  is  rarely  attended 
with  much  constitutional  disturbance.  A  child  is  often 
rendered  restless  by  thirst,  and  will  be  quieted  and  re- 
lieved by  a  little  clear  cold  water.  This  should  always 
be  given  at  least  twice  a  day.  After  eight  or  ten  months 
the  daily  meals  should  not  exceed  six  in  number.  An 
allowance  of  bread  and  milk,  or  beef -tea,  may  be  given, 
but  it  should  not  come  to  depend  upon  solid  food  until 
all  the  teeth  are  cut.  Contrary  to  the  common  impres- 
sion, thick  food  is  less  nutritious  than  thin.  The  first 
teeth  may  be  looked  for  at  about  the  sixth  or  eighth 
month,  and  the  others  at  intervals,  until  the  first  set  of 
twenty  is  complete,  at  about  the  age  of  two  years.  The 
process  of  dentition  may  be  accompanied  by  various 
functional  disorders.  It  unsettles  the  healthy  balance 
of  the  system,  and  predisposes  to,  if  it  does  not  exactly 
cause,  disease.  The  child  may  be  restless  and  feverish; 
diarrhoea  is  common;  sometimes  even  croup  and  con- 
vulsions occur.  These  need  medical  advice,  as  at  other 
times,  and  great  attention  must  be  paid  to  general  nurs- 
ing and  dieting.  Keep  the  little  one  in  the  open  air  as 
much  as  possible,  suitably  clothed.  If  the  gums  are 
very  painful  and  swollen,  it  may  be  necessary  to  have 
them  lanced. 

A  high  degree  of  development  of  those  qualities  de- 
sirable in  any  nurse  is  requisite  in  the  care  of  sick  chil- 
dren. This  calls  for  infinite  tact,  patience,  and  judg- 
ment, and  especially  is  the  habit  of  critical  observation 


296  A  TEXT-BOOK  OF  NURSING 

essential,  for,  with  children  too  young  to  speak,  the  in- 
voluntary revelations  of  signs  and  gestures  give  often 
the  only  clew  to  the  seat  and  kind  of  distress.  The  ob- 
jective symptoms  are,  fortunately,  very  marked  in  chil- 
dren, and  they  respond  to  treatment  with  a  readiness 
which  makes  them  very  interesting  subjects.  A  good 
deal  may  be  learned  from  the  character  of  a  baby's  cry. 
With  abdominal  pain  the  cry  will  be  long,  loud,  and 
tearful,  subsiding,  as  the  pain  is  relieved,  into  long- 
drawn  sobs.  The  legs  will  be  drawn  up  to  relax  the 
strain  on  the  abdominal  muscles.  If  there  is  inflamma- 
tion of  the  chest,  there  will  be  less  tears  and  less  noise, 
the  cry  begun  after  each  deeper  breath  or  cough  will  be 
sharp  and  suppressed,  evidently  augmenting  the  pain. 
Sharp  screams,  alternating  with  low  moans  or  stupor, 
suggest  some  affection  of  the  brain.  Waking  suddenly 
with  a  cry,  grinding  the  teeth,  or  starting  nervously  in 
the  sleep  and  boring  the  head  into  the  pillow  are  all 
noteworthy  symptoms  in  children.  No  departure  from 
the  usual  habits  of  the  child  is  unimportant.  Note 
whether  it  is  unusually  stupid,  restless,  or  irritable,  in 
what  position  it  seems  most  easy,  whether  the  light  oc- 
casions distress,  and  whether  the  general  symptoms  of 
disorder  increase  in  severity  toward  night.  The  tem- 
perature should  be  taken  in  the  rectum.  If  a  child 
complains  of  pain  anywhere,  and  has  a  rise  of  tempera- 
ture, it  is  safe  to  examine  the  throat.  The  pulse  of  an 
infant  can  only  be  taken  with  any  approach  to  accuracy 
during  sleep.  A  very  slow  pulse  is  more  ominous  in  a 
child  than  a  rapid  one.  Children  gain  and  lose  flesh 
with  great  rapidity,  showing  it  first  on  the  inner  side 
of  the  thighs,  where  two  or  three  days'  illness  will  have 
a  marked  effect. 

In  dealing  with  sick  children  the  utmost  gentleness 


SICK  CHILDREN  297 

is  necessary.  They  ought  never  to  be  frightened  or 
startled.  It  is  a  bad  time  to  introduce  a  stranger  to  a 
shy  baby  when  it  is  sick,  and  the  first  thing  to  be  done 
— often  a  very  difficult  thing  to  do — is  to  acquire  the 
child's  confidence.  Until  it  has  become  accustomed  to 
your  presence,  it  may  be  best  to  allow  everything  to  be 
done  for  it  by  the  mother  or  usual  attendant,  while  you 
merely  give  directions.  A  child  accustomed  to  unlim- 
ited indulgence,  afraid  of  strangers,  and  fretful  from 
pain  is  not  an  easy  patient  to  manage;  it  will  require 
winning  tact  and  a  genuine  sympathy  for  the  little  one 
to  get  even  the  possibility  of  caring  for  it  helpfully. 
Whatever  excites  or  alarms,  does  the  child  harm,  mak- 
ing it  nervous  and  feverish.  Do  not  give  too  many  toys 
in  the  effort  to  divert,  one  at  a  time  is  better  than  a 
dozen,  and,  above  all,  do  not  let  the  child  see  any  that 
it  can  not  have.  Children  may  be  attacked  by  many  of 
the  same  diseases  as  older  people;  there  are  also  some 
which  are  peculiar  to  them,  and  others  which  appear 
most  frequently  in  early  life.  When  a  child  first  ex- 
hibits indisposition,  it  is  always  safe,  and  often  sooth- 
ing, to  put  it  in  a  warm  bath.  This  will  tend  to  bring 
out  any  latent  rash,  for  which  the  whole  body  should 
be  carefully  examined.  The  room  should  be  warm  and 
free  from  draughts,  the  temperature  of  the  bath  100° 
Fahr.,  and  the  child  allowed  to  remain  in  it  about  five 
minutes.  If  the  baby  is  afraid  of  the  water,  prepare 
the  bath  out  of  sight,  and  cover  it  with  a  blanket.  The 
child  can  then  be  gradually  let  down  into  the  water, 
blanket  and  all,  without  any  shock.  When  taken  out,  it 
should  be  wrapped  in  a  soft  dry  blanket  for  a  few  mo- 
ments, and  then  dried  with  soft  towels.  Guard  against 
exposure,  keep  as  quiet  as  possible,  on  the  simplest  diet, 
and  watch  carefully  for  further  signs  of  disorder. 


298  A  TEXT-BOOK  OF  NURSING 

Thrush  or  sprue  is  a  sort  of  fungoid  growth  appear- 
ing in  the  form  of  white  spots  on  the  tongue  and  inside 
of  the  mouth.  It  may  result  from  improper  food,  or 
from  neglect  to  wash  out  the  child's  mouth  after  eating. 
Particles  of  milk  remaining  in  the  mouth  decompose, 
and  set  up  fermentation.  The  remedy  most  frequently 
prescribed  is  a  wash  of  borax  water,  gr.  xx-§  j.  Errors 
of  diet  should  be  corrected,  and  great  attention  paid  to 
the  cleanliness  of  feeding-bottles,  etc.  If  it  is  allowed 
to  spread,  it  may  extend  into  the  throat  and  cause  dif- 
ficulty in  swallowing,  or  even  attack  the  stomach,  when 
it  may  prove  fatal.  It  is  a  serious  indication  if  an  erup- 
tion appears  about  the  anus  simultaneously  with  thrush 
in  the  mouth. 

Ophthalmia  neonatorum. — Soreness  of  the  eyes  in  a 
young  child  is  a  serious  matter,  requiring  prompt  atten- 
tion. A  purulent  exudation  may  occur,  inflaming  the 
lids  and  gumming  them  together.  This  is  usually  in 
consequence  of  some  infection  received  at  the  time  of 
birth  from  the  maternal  discharges,  and  first  manifests 
itself  about  the  third  day.  It  is  in  order  to  guard 
against  this  that  so  much  care  is  taken  to  cleanse  the 
eyes  thoroughly  immediately  after  delivery.  Should 
the  least  sign  of  such  inflammation  be  observed,  the 
eyes  must  be  frequently  bathed  with  warm  water  or  a 
solution  of  boric  acid,  and  the  greatest  care  be  taken  to 
prevent  the  spread  of  the  disease,  for  the  discharges  are 
highly  infectious,  and  the  danger  of  contagion  is  not 
confined  to  children.  In  bathing  the  eyes,  separate  the 
lids  without  making  any  pressure  on  the  eyeball,  and 
let  a  stream  of  clean  warm  water  trickle  over  the 
surface,  always  in  the  direction  from  the  nose  to  the 
outer  angle.  Do  not  rub  them  in  the  least,  but  re- 
peat the  syringing  until  they  are  entirely  free  from 


SICK  CHILDREN  299 

matter.  It  may  be  necessary  to  do  this  every  hour. 
A  little  absorbent  cotton  will  serve  to  hold  the  water, 
or  a  perfectly  clean  medicine  dropper  may  be  used. 
If  they  do  not  show  improvement  promptly,  the  gran- 
ulations should  be  touched  with  a  solution  of  nitrate 
of  silver,  gr.  xl-§  j.  Burn  at  once  the  cotton  and  any 
cloths  used  about  the  eyes,  and  disinfect  your  own 
hands  most  carefully,  scouring  the  nails  with  a 
brush.  Do  not  touch  your  own  eyes  with  your  fingers 
before  they  are  cleaned,  and  if  one  eye  only  of  the 
child  is  affected,  lay  it  down  always  on  that  side, 
that  the  other  may  not  be  contaminated.  Neglect  of 
this  trouble  for  a  few  days  may  result  in  total  loss  of 
sight. 

The  most  common  troubles  of  children  are  disor- 
ders, more  or  less  severe,  of  the  digestive  tract.  In  the 
case  of  a  feeble  child  unable  to  take  or  retain  food, 
"  gavage  "  or  forced  feeding  may  have  to  be  resorted 
to.  For  this  purpose  a  rubber  catheter  is  used,  con- 
nected at  the  open  end  with  a  small  glass  funnel.  The 
point  of  the  catheter  introduced  at  the  back  of  the 
tongue  or  through  the  nose  will  be  instinctively  swal- 
lowed, after  which  the  food  is  poured  into  the  funnel, 
and  after  a  few  seconds  quickly  removed.  If  skillfully 
done,  the  food  will  be  retained.  Washing  out  the  stom- 
ach by  the  aid  of  a  similar  apparatus  has  in  some  cases 
been  found  beneficial. 

Colic. — The  wind  colic  of  infants,  though  distress- 
ing, seldom  requires  medical  treatment.  If  persistent, 
it  is  probably  due  to  unsuitable  food;  or,  in  the  case  of 
a  nursing  baby,  to  the  condition  of  the  mother.  Do  not 
give  soothing-sirups.  Eubbing  and  the  application  of 
hot  flannels  to  the  abdomen  will  usually  relieve  it.  A 
Uttle  hot  water  flavored  with  peppermint  or  anise  may 


300  A  TEXT-BOOK  OP  NURSING 

be  given,  or,  if  this  fail,  try  two  or  three  drops  of  gin 
in  hot  water. 

Diarrhoea. — When  diarrhoea  is  present,  a  little  cal- 
cined magnesia  or  castor  oil  may  be  given.  Put  a  flan- 
nel band  about  the  bowels,  and  be  sure  to  keep  the 
child  warm.  The  skin  is  apt  to  become  chafed  and  sore; 
scrupulous  attention  must  be  given  to  cleanliness.  In 
place  of  soap  and  water,  very  thin  starch  may  be  used 
and  will  be  found  soothing.  Dry  carefully,  and  dust 
with  talcum  powder,  or  dry  starch.  If  the  diarrhoea  is 
long  continued,  it  will  be  exhausting.  Have  medical  ad- 
vice, and  do  not  give  paregoric  without  it. 

Constipation. — When  there  is  a  tendency  to  consti- 
pation, rub  the  bowels  night  and  morning  with  warm 
olive  oil.  Oatmeal  gruel  will  be  a  helpful  diet.  A  small 
suppository  of  Castile  soap  will  usually  induce  a  move- 
ment. Gluten  or  glycerin  suppositories  are  also  good. 
Water,  given  abundantly,  helps  to  regulate  the  intes- 
tinal action.  It  is  well  to  establish  regular  habits  in 
children,  and  with  a  little  pains  it  can  be  done  early; 
but  it  is  most  injudicious  to  urge  them  to  strain  until 
something  has  been  accomplished. 

Protrusion  of  the  bowel  may  be  caused  by  straining. 
If  it  has  occurred,  lay  the  child  on  its  back,  with  the 
hips  elevated,  wash  the  parts  carefully  in  tepid  water, 
and  replace  the  bowel  very  gently,  after  oiling  the  fin- 
gers. If  it  can  not  be  done  readily,  the  child  must  be 
kept  quiet,  and  the  doctor  sent  for. 

Worms. — Delicate  children  are  sometimes  troubled 
by  worms  in  the  intestine.  Eound  and  pin  worms  are 
the  most  common.  The  tape-worm  is  more  often  found 
in  adults.  It  is  desirable  for  the  nurse  to  become  ac- 
quainted with  these  parasites,  in  order  that  she  may 
recognize  them.  The  only  positive  indication  is  their 


SICK  CHILDREN  301 

presence  in  the  stools.  A  dose  of  castor  oil  may  be 
given,  and,  after  it  has  operated,  injections  of  warm 
water  and  salt  daily  until  the  trouble  is  at  an  end.  An 
infusion  of  quassia  chips  may  be  injected  twice  daily 
for  three  days. 

Incontinence  of  Urine. — Nocturnal  incontinence  is 
a  common  trouble  among  children,  and  one  for  which 
medical  advice  is  necessary.  It  should  be  cured  before 
it  becomes  a  confirmed  habit,  but  scolding  or  punishing 
the  child  will  not  do  it.  The  simplest  plan  is  to  make 
the  child  rise  during  the  night  to  pass  its  water. 

Cholera  Infantum  is  one  of  the  most  fatal  diseases 
among  young  children.  It  usually  begins  with  diar- 
rhoea or  indigestion.  It  comes  from  overfeeding,  heat, 
and  impure  air,  and  is  aggravated  by  teething,  though 
never  caused  by  it.  The  child  loses  flesh  rapidly,  be- 
comes restless  and  feverish,  has  intestinal  pain  and  ex- 
cessive thirst,  but  no  appetite,  and  the  food  is  not  as- 
similated. Medical  advice  should  be  summoned  early. 
The  child  should  be  kept  cool  and  much  in  the  open 
air.  Entire  change  of  air  is  advisable. 

Convulsions  in  children  may  result  from  indigestion, 
worms,  difficult  dentition,  fright,  or  any  extreme  nerv- 
ous excitement.  Muscular  twitchings  come  on  sudden- 
ly, sleeping  or  waking.  The  fits  usually  last  only  a  few 
moments;  a  succession  of  them  is  alarming.  The  doc- 
tor should  be  at  once  sent  for,  but  treatment  should 
not  await  his  arrival.  Eemove  the  clothing  with  as 
little  disturbance  as  may  be,  and  put  the  child  in  a 
warm  bath.  Keep  the  head  cool.  An  enema  of  soap- 
suds may  be  given,  or  a  dose  of  castor  oil.  If  the  tem- 
perature rises  to  103°,  put  in  a  cold  pack. 

Croup  is  an  inflammation  of  the  larynx  and  trachea. 
It  may  come  on  gradually,  with  a  cold  in  the  head, 


302  A  TEXT-BOOK  OF  NURSING 

wheezing,  hoarseness,  and  short,  dry  cough,  or  the  child 
may  be  wakened  in  the  night  by  sudden  dyspnoea  and 
violent  choking.  There  will  be  a  long-drawn  inspiration, 
accompanied  by  a  characteristic  sound,  a  ringing  cough, 
the  voice  will  be  husky,  the  skin  hot  and  dry.  There 
are  two  varieties — membranous  croup,  usually  fatal, 
and  spasmodic  croup,  rarely  so.  The  former  is  of  rare 
occurrence  as  compared  with  the  latter.  The  treat- 
ment until  the  doctor  arrives  is  in  either  case  the  same. 
Keep  the  temperature  of  the  room  not  lower  than  65°, 
and  a  tea-kettle  boiling  to  moisten  the  air.  If  the 
breathing  is  labored,  give  an  emetic — the  sirup  of  ipecac 
in  drachm  doses  is  in  common  use — and  repeat  at  in- 
tervals of  half  an  hour  until  there  is  free  vomiting. 
Give  a  hot  bath.  Hot  stupes  around  the  throat  will 
sometimes  afford  relief.  Prop  the  child  up  with  pillows, 
and  keep  it  quiet,  avoiding  everything  that  will  excite 
crying  or  coughing.  Simple  spasmodic  croup  usually 
yields  readily  to  treatment,  though  the  attacks  are  like- 
ly to  recur,  and  the  child  must  be  protected  with  extra 
care  for  some  days.  Membranous  croup  is  character- 
ized by  an  exudation  of  false  membrane  in  the  throat, 
and  is  by  many  authorities  considered  identical  with 
diphtheria.  The  early  symptoms  are  much  the  same 
as  those  above  described;  as  the  disease  progresses,  the 
child  becomes  dull,  irritable,  and  disinclined  to  speak. 
The  head  is  thrown  back,  the  face  distressed  and  bathed 
in  cold  perspiration.  In  the  last  stages  stupor  comes 
on,  from  which  the  child  must  be  roused  for  nourish- 
ment. This  can  only  be  given  in  small  quantities. 
When  the  air  passages  become  obstructed,  tracheotomy 
is  sometimes  resorted  to,  or  more  commonly  now  intu- 
bation of  the  larynx. 

Whooping-cough  begins  like  an  ordinary  cold,  the 


SICK  CHILDREN  303 

peculiar  whoop  not  being  heard  until  after  the  first  ten 
days.  It  lasts  from  one  to  three  months.  The  child 
should  be  kept  out  of  doors  if  the  weather  is  fit,  and 
should  have  a  light,  unstimulating  diet,  special  care  be- 
ing  taken  to  avoid  constipation.  The  chief  danger  is  of 
bronchitis  or  inflammation  of  the  lungs  supervening. 

In  all  diseases  of  the  lungs  or  air  passages  the  child 
should  be  kept  quiet,  in  an  even  temperature,  with  pure 
air.  The  head  should  be  well  elevated,  as  the  breathing 
will  be  less  labored  in  a  nearly  upright  position.  The 
sputa  will  generally  be  swallowed  by  young  children, 
and  will  sometimes  be  vomited  up  in  quantity. 

Mumps  is  another  common  juvenile  disease,  not 
very  dangerous.  It  is  an  inflammation  of  the  salivary 
glands,  chiefly  the  parotid,  and  may  affect  one  or  both 
sides,  together  or  successively.  There  will  be  pain  and 
swelling  under  the  ear,  with  difficulty  in  swallowing, 
or  even  in  speaking.  Hot  applications  afford  the  most 
relief.  If  there  is  suppuration,  which  is  rare,  poultice. 
There  will  be  more  or  less  fever,  and  some  slight  laxa- 
tive may  be  required.  The  disease  reaches  its  height 
in  three  or  four  days,  then  declines  rapidly. 

Chicken-pox,  or  varicella,  commences  with  slight 
fever.  After  twenty-four  hours  "an  eruption  of  reddish 
pimples  appears,  generally  thickest  on  the  back.  In  a 
day  or  two  these  become  blisters,  and  within  a  week 
disappear.  Little  medication  is  called  for.  A  warm 
bath  may  be  of  service.  Isolate  the  patient  if  there  are 
other  children. 

Measles  (rubeola)  is  a  disease  not  confined  to  chil- 
dren, but  is  most  common  among  them.  It  begins  like 
an  attack  of  acute  catarrh,  with  sneezing,  coryza, 
hoarseness,  sore  throat,  cough,  dyspnoea,  and  some 
fever.  The  average  period  of  incubation  is  eight  days. 


304  A  TEXT-BOOK  OP  NURSING 

The  eruption  of  pimples  comes  out  not  later  than  the 
fourth  day  from  the  appearance  of  the  first  symptoms, 
in  dark,  somewhat  crescent-shaped  patches,  first  on  the 
face,  neck,  and  arms,  later  on  the  trunk  and  legs.  This 
lasts  from  two  to  five  days,  then  fades  in  the  order  of 
appearance,  leaving  a  brownish  stain  and  mealy  des- 
quamation  for  a  week.  At  this  time  diarrhoea  is  apt  to 
set  in.  The  disease  itself  is  not  likely  to  be  severe  in 
a  child,  but  is  often  complicated  or  followed  by  bron- 
chitis, pneumonia,  gastric  troubles,  ophthalmia,  or  otor- 
rhoea — inflammation  of  the  ear.  To  avoid  such  sequelae, 
great  care  is  required,  even  after  convalescence  is  es- 
tablished. The  child  should  be  kept  in  bed,  and  on  light 
diet,  until  all  feverishness  has  left  it.  Great  warmth  is 
not  required,  but  protection  from  draughts  is  impor- 
tant. The  eyes  should  be  shielded  from  strong  light, 
and  care  be  taken  not  in  any  way  to  strain  them.  A 
generally  lowered  tone  of  the  system  may  persist  for 
some  time. 

Roseola,  or  German  measles,  is  a  fugitive  eruption, 
lasting  a  few  hours  or  days,  very  mild,  but  is  supposed 
to  be  contagious.  A  second  attack  of  either  this  or  true 
measles  is  rare. 

Acute  meningitis  is"  a  disease  also  most  common  in 
children  under  five  years  of  age.  The  symptoms  vary 
vejy  much.  It  most  often  comes  on  gradually,  with 
wasting  of  the  body,  disordered  bowels,  capricious  ap- 
petite, nausea,  headache,  fever,  irritability,  intolerance 
of  light  and  noise.  The  child  may  seem  constantly 
drowsy,  but  the  sleep  is  restless  and  disturbed.  Squint- 
ing and  enlarged  glassy  pupils  are  common  symptoms. 
As  the  disease  progresses,  convulsions  or  paralysis  may 
occur,  or  the  patient  sink  into  a  comatose  condition. 
Perfect  quiet  is  an  essential  part  of  the  treatment. 


SICK  CHILDREN  305 

Keep  the  child  in  a  dark  room,  in  bed,  with  the  head 
elevated.  Do  not  rock  or  walk  about  with  him,  or  in 
any  way  move  him  unnecessarily.  Do  not  startle  or 
excite  him.  Cold  applications  to  the  head  will  probably 
be  ordered,  and  purgatives.  Only  the  lightest  food 
should  be  given. 

Hydrocephalus. — Water  on  the  brain  is  an  affection 
of  early  childhood  due  to  an  abnormal  accumulation  of 
fluid  in  the  brain.  The  head  in  these  cases  will  be 
very  large,  and  the  fontanelles  fail  to  close.  Intelli- 
gence does  not  develop,  and  death  usually  takes  place 
soon. 

Rachitis. — The  disease  commonly  known  as  rickets 
is  most  commonly  met  with  among  the  poorer  classes, 
and  is  due  chiefly  to  bad  feeding  and  bad  air.  There 
are  the  general  symptoms  of  malnutrition  and  digestive 
derangements  with  marked  tendency  to  pulmonary  com- 
plications. The  child  is  feeble  and  irritable,  with  en- 
larged head  and  distended  abdomen,  sallow  and  emaci- 
ated, and  perspires  profusely.  The  bones  lack  firmness, 
in  consequence  of  a  deficiency  of  lime-salts,  and  are 
often  misshapen  and  deformed.  The  treatment  consists 
in  improving  the  general  hygienic  condition,  correcting 
the  diet,  and  insisting  upon  cleanliness  and  fresh  air. 
The  disease  itself  is  not  directly  dangerous  to  life,  but 
it  lowers  the  resistive  powers  to  such  an  extent  that  its 
complications  are  often  fatal. 

"Never  fear  to  bring  the  sublimest  motive  to  the  smallest 
duty,  and  the  most  infinite  comfort  to  the  smallest  trouble." — 
Phillips  Brooks. 


CHAPTER   XVIII 

"  And  ye  shall  succor  men: 
Tis  nobleness  to  serve ; 
Help  them  who  can  not  help  again, 
Beware  from  right  to  swerve." 

R.  W.  Emerson. 

THERE  are  a  few  special  diseases  for  the  care  of 
which  some  special  directions  may  be  needed,  supple- 
mentary to  the  general  directions  for  nursing  in  all 
cases.  Although  a  slight  attempt  is  made  at  describing 
them,  it  is  not  to  be  expected  that  any  given  case  will 
correspond  exactly  with  the  type  except  in  general  fea- 
tures. Variations  and  complications  are  endless,  and 
clinical  diagnosis  is  not  expected  of  you;  but  you  will 
find  it  an  advantage  to  know  what  course  a  disease 
naturally  takes  and  what  dangers  are  especially  to  be 
guarded  against. 

Let  us  first  consider  the  diseases  of  the  respiratory 
organs. 

Catarrh  of  the  nasal  mucous  membrane — cold  in  the 
head — is  so  common  as  to  need  little  description,  and  is 
one  of  the  cases  in  which  an  ounce  of  prevention  is 
worth  many  a  pound  of  cure.  Ill-ventilated  and  over- 
heated houses  are  responsible  for  much  of  the  suscepti- 
bility to  colds.  Pure  air,  warm  clothing  and  dry  feet 
are  the  best  preventives.  If  taken  in  the  earliest  stage, 
a  full  dose  of  quinine  will  sometimes  abort  a  cold.  Ten 
grains  of  Dover's  powder  taken  at  bed-time  will  often 
306 


SPECIAL  MEDICAL  CASES  307 

cut  it  short.  Once  established,  little  can  be  done  except 
to  avoid  adding  to  it.  It  will  usually  pass  off  after  a 
few  days  without  any  special  treatment.  The  discharge 
from  the  nose,  technically  known  as  coryza,  may  be  re- 
lieved by  the  inhalation,  through  a  paper  cone,  of  the 
vapors  arising  from  a  solution  of  pulverized  camphor 
or  compound  tincture  of  benzoin,  about  a  teaspoonful 
in  a  pint  of  boiling  water.  Neglected  colds  may  result 
in  a  condition  of  chronic  catarrh,  very  difficult  to  over-« 
come,  or  may  even  lead  to  dangerous  pulmonary  disease. 
Ozaena  is  a  chronic  form,  marked  by  a  peculiarly  strong 
and  offensive  odor. 

Influenza,  or  la  grippe,  is  an  infectious  epidemic, 
caused  by  a  specific  micro-organism,  characterized  by 
a  catarrh al  process  of  the  respiratory  tract.  It  begins 
like  a  sudden  and  severe  cold,  accompanied  by  more 
or  less  fever,  with  rapid  pulse,  increased  and  shortened 
respirations,  cough,  coryza,  loss  of  appetite,  general 
pain,  especially  in  the  head  and  the  lumbar  region, 
marked  prostration  and  nervous  depression.  Pleurisy 
and  pneumonia  frequently  ensue.  The  subsequent  ex- 
haustion and  debility  are  extreme,  and  care  during  con- 
valescence is  especially  important.  There  are  three 
common  types,  nervous,  gastro-intestinal,  and  simple 
febrile. 

Prophylaxis  is  the  main  consideration,  and  should 
consist  in  maintaining  the  best  possible  hygienic  con- 
ditions during  the  prevalence  of  the  disease,  and  tak- 
ing the  greatest  care  in  thoroughly  sterilizing  all  eating 
utensils,  napkins,  handkerchiefs,  etc.,  before  removing 
them  from  the  sick-room.  The  bacilli  are  in  the  secre- 
tions from  the  mouth  and  nose,  and  are  readily  trans- 
mitted through  the  air.  The  walking  cases  are  prob- 
ably the  greatest  disseminators  of  the  disease.  Absolute 


308  A  TEXT-BOOK  OP  NURSING 

rest  in  bed  is  the  most  important  part  of  the  treatment. 
The  pains  may  be  relieved  by  local  applications  of  heat 
or  cold,  as  may  be  found  most  effective,  and  the  cough 
by  a  mustard-plaster  on  the  chest.  The  patient  should 
be  encouraged  to  take  food,  and  stimulants  may  also 
be  indicated.  Whisky  and  milk,  and  quinine  may  in 
most  cases  be  given. 

Bronchitis  is  an  inflammation  of  the  bronchial  tubes, 
acute  or  chronic.  Capillary  bronchitis  is  the  most  dan- 
gerous form.  The  acute  disease  begins  with  a  heavy 
cold,  sometimes  ushered  in  by  slight  chills.  There  is 
fullness  in  the  head,  sore  throat,  general  malaise,  with 
pain  in  the  chest  and  cough,  at  first  dry  and  then  ac- 
companied by  watery  sputa,  which  later  becomes  viscid 
and  purulent.  As  the  dyspnoea  increases,  there  may  be 
high  fever,  rapid  pulse,  and  profuse  perspiration.  The 
patient  must  be  kept  in  one  room,  well  aired,  at  an  even 
temperature  not  higher  than  68°  Fahr.  Free  action  of 
the  skin  is  to  be  secured,  and  the  bowels  opened.  A 
mustard  plaster  on  the  chest  may  relieve  the  pain,  and 
inhalations  of  steam  allay  the  cough.  Plenty  of  nour- 
ishing food  should  be  given.  During  convalescence 
special  care  should  be  taken  to  avoid  sudden  changes  of 
temperature,  as  the  patient  will  be  very  susceptible  to 
chills.  In  the  majority  of  cases,  recovery  may  be  looked 
for,  but  it  is  sometimes  fatal,  or  may  assume  a  chronic 
form. 

Asthma  is  a  form  of  dyspnoea,  caused  by  spasmodic 
contraction  of  the  bronchial  tubes,  for  which  you 
should  know  the  popular  remedies  in  case  of  emer- 
gency. It  is  often  associated  with  chronic  bronchitis. 
It  is  rarely  dangerous,  but  always  distressing.  The 
patient  gasps  violently  for  air,  his  expression  is  anx- 
ious, pulse  feeble,  the  skin  cold  and  pale  or  cyanosed. 


SPECIAL  MEDICAL  CASES  309 

Elevate  the  arms,  and  give  all  the  air  possible.  A 
drachm  of  Hoffmann's  anodyne  may  be  administered, 
and  repeated  after  half  an  hour  if  the  condition  is  not 
relieved.  It  may  last  for  several  hours,  and  is  usually 
concluded  by  a  paroxysm  of  coughing  and  a  free  ex- 
pectoration of  mucus.  Blotting-paper  which  has  been 
saturated  with  a  strong  solution  of  saltpetre  and  dried 
affords,  when  burned,  fumes  that  may  give  relief;  stra- 
monium leaves  rolled  into  cigarettes,  or  smoked  in  a 
pipe  like  tobacco,  are  sometimes  ordered. 

Laryngitis  is  an  inflammation  of  the  lining  mem- 
brane of  the  throat  extending  into  the  larynx.  It  may 
result  from  cold  or  local  irritation,  or  may  be  associated 
with  pulmonary  tuberculosis.  There  is  hoarseness  of 
the  voice,  sore  throat,  usually  some  fever,  and  .in  the 
more  severe  cases,  difficulty  of  breathing  in  consequence 
of  the  swelling.  Treat  with  steam  inhalations,  and 
rub  the  throat  with  camphorated  oil. 

Pleurisy  is  an  inflammation  of  the  serous  membrane 
covering  the  lungs,  and  often  occurs  as  a  complication 
of  pulmonary  disease.  The  surfaces  of  the  membrane 
become  dry  and  no  longer  slide  easily  over  each  other. 
There  is  acute  pain  on  inspiration,  short,  repressed 
cough,  inability  to  draw  a  long  breath,  some  elevation 
of  temperature,  often  preceded  by  a  sense  of  chilliness. 
The  pain  may  be  relieved  by  the  external  application 
of  counter-irritants  and  the  disease  may  subside  at  this 
stage,  or  the  inflammation  may  continue,  and  an  effu- 
sion of  fluid  into  the  pleural  cavity  may  take  ^place. 
This  may  be  so  abundant  as  to  embarrass  the  action  of 
the  lungs  and  heart.  The  acute  pain  of  the  first  stage 
will  be  diminished,  but  there  will  be  increased  fever  and 
dyspnoea.  In  order  to  relieve  this  condition,  aspiration 
may  be  necessary,  an  operation  which  consists  in  draw- 
21 


310  A  TEXT-BOOK  OF  NURSING 

ing  off  the  fluid  through  a  hollow  needle.  This  should 
always  be  saved  for  examination.  It  is  usually  simply 
a  serous  fluid  of  amher  hue,  hut  in  some  cases  there 
will  be  an  accumulation  of  pus.  This  form  of  pleurisy 
is  termed  empyema,  and  necessitates  a  free  opening 
and  thorough  drainage  of  the  pleural  cavity.  It  may 
also  have  to  be  washed  out  with  some  antiseptic  fluid. 
As  soon  as  the  cavity  is  emptied,  the  temperature  will 
begin  to  fall. 

Pneumonia,  inflammation  of  the  lung  substance,  is 
one  of  the  most  serious  of  the  pulmonary  affections.  It 
may  occur  independently  or  as  a  complication  in  the 
course  of  some  other  disease.  One  or  both  sides  may 
be  affected,  more  often  the  right  lung  alone.  It  is 
usually  initiated  by  a  chill,  or  sense  of  chilliness,  with 
deep-seated  pain,  and  shortness  of  breath.  High  fever 
follows,  with  flushed  face,  often  on  one  side  only,  head- 
ache, and  restlessness.  The  respirations  are  shallow 
and  rapid.  The  urine  is  scanty  and  high-colored.  The 
cough  is  short  and  hacking,  the  expectoration  at  first 
scanty.  After  twelve  or  eighteen  hours,  it  may  be  ex- 
pected to  increase  in  quantity,  and  to  assume  a  tough, 
tenacious  quality,  highly  characteristic.  It  may  be  rust- 
colored  or  streaked  with  blood.  The  sputa  should  be 
carefully  preserved  for  the  doctor's  inspection.  The 
disease  reaches  its  height  by  the  end  of  the  first  week; 
in  those  cases  which  terminate  by  resolution — gradual 
restoration  of  the  inflamed  part  to  a  normal  condition 
— the'  febrile  symptoms  rapidly  decline.  When  sup- 
puration takes  place  the  fever  is  likely  to  continue  a 
week  or  two  longer.  There  is  a  tendency  to  delirium, 
especially  at  night.  The  great  danger  is  failure  of  the 
heart.  The  patient  must  be  kept  in  bed,  absolutely 
quiet,  and  on  fluid  diet.  Save  his  strength  in  every  pos- 


SPECIAL  MEDICAL  CASES  311 

sible  way;  do  not  allow  unnecessary  talking,  or  any  exer- 
tion. Be  careful  not  to  overload  the  stomach,  though 
nourishment  is  of  the  first  importance  and  stimulants 
may  be  necessary.  Convalescence,  once  established,  will 
be  rapid.  With  pneumonia  in  alcoholic  subjects,  nerv- 
ous symptoms  are  prominent,  and  the  characteristic 
sputa  may  be  absent. 

Phthisis,  or  pulmonary  consumption,  is  a  disease  al- 
most always  fatal  sooner  or  later,  characterized  by  a 
morbid  deposit  of  tubercles  in  the  lungs.  These  tuber- 
culous nodules  may  attack  other  parts  of  the  body  also, 
and  have  a  great  tendency  to  spread.  The  disease  is 
distinctly  infectious,  and  a  hereditary  susceptibility  to 
it  has  been  observed.  Exposure,  overwork,  and  intem- 
perance favor  its  development.  The  course  of  the  dis- 
ease may  be  acute,  terminating  in  a  few  weeks,  or 
chronic,  lasting  for  several  years.  It  most  commonly 
attacks  persons  under  thirty  years  of  age.  The  symp- 
toms vary.  The  most  characteristic  are  the  cough, 
fever,  night  sweats,  spitting  of  blood,  gastric  derange- 
ment, with  loss  of  appetite,  gradual  emaciation,  and 
increasing  weakness.  The  onset  is  usually  gradual,  and 
periods  of  apparent  improvement  may  occur,  but  it  is 
rarely  permanent,  and  the  patient  finally  dies  either 
from  haemorrhage  or  exhaustion.  The  distressing  symp- 
toms may  be  alleviated,  but  treatment  which  will  posi- 
tively arrest  the  progress  of  the  disease  is  yet  to  be  dis- 
covered. Change  of  climate  may  exert  a  beneficial  in- 
fluence. If  that  is  impracticable,  some  out-of-door 
occupation  should  be  adopted,  for  life  in  the  open  air 
offers  almost  the  only  chance  for  recovery.  A  dry  at- 
mosphere with  plenty  of  sun  and  free  from  wind  is  the 
most  desirable.  Defective  ventilation  and  overcrowd- 
ing are,  of  all  things,  to  be  avoided.  Liberal  diet  is 


312  A  TEXT-BOOK  OP  NURSING 

important,  though  there  is  often  defective  assimilation 
as  well  as  lack  of  appetite.  Thorough  disinfection  of 
the  sputum  is  of  vital  importance.  Old  cloths  or  soft 
Japanese  napkins  should  be  substituted  for  handker- 
chiefs, and  the  sputum  cups  lined  with  paper,  all  of 
which  should  be  promptly  burned. 

The  most  common  forms  of  cardiac  disorder  are 
pericarditis,  endocarditis,  valvular  diseases  of  the  heart, 
dilatation,  and  fatty  degeneration.  They  occur  in  the 
majority  of  cases  as  sequelae  or  complications  of  other 
diseases,  notably  of  rheumatism.  All  that  a  nurse 
needs  to  know  about  these  is  the  special  care  required 
by  patients  subject  to  them,  and  how  to  treat  the  alarm- 
ing symptoms  which  sometimes  occur.  With  all  cardiac 
cases,  overexertion  and  occasions  of  excitement  are  to 
be  guarded  against,  and  in  the  matter  of  diet  the  doc- 
tor's directions  should  be  most  carefully  followed.  Any- 
thing which  accelerates  the  circulation  is  likely  to  bring 
on  palpitation  and  dyspnoea.  In  severe  cases,  the  diffi- 
culty in  breathing  may  occasion  great  distress  even 
when  the  patient  is  in  bed  and  entirely  quiet.  The  re- 
cumbent position  may  be  rendered  impossible  from  this 
cause.  Difficulty  in  the  return  of  blood  to  the  heart 
may  result  in  dropsy,  and  exudation  of  serum  from  the 
veins  into  the  connective  tissue  and  the  cavities  of  the 
body.  General  dropsy  is  termed  anasarca.  An  accu- 
mulation of  such  fluid  in  the  peritoneal  cavity  is  known 
as  ascites;  this  may  occasion  so  great  distention  as  to 
interfere  with  the  movements  of  the  diaphragm,  and 
must  then  be  removed  by  tapping.  Fluid  in  the  con- 
nective tissues  produces  a  swelling  called  oedema.  This 
will  be  most  marked  where  the  skin  is  loose.  Pressure 
with  the  finger  upon  an  cedematous  swelling  will  make 
a  distinct  indentation,  which  does  not  immediately  dis- 


SPECIAL  MEDICAL  CASES  313 

appear  when  the  pressure  is  removed.  Dyspnoea  and 
dropsy  are  two  symptoms  which  occur  either  together 
or  separately  in  nearly  all  serious  affections  of  the  heart. 

Angina  pectoris  is  the  name  given  to  certain  attacks 
of  intense  and  characteristic  pain  sometimes  occurring 
in  connection  with  heart-disease.  The  spasms  are  sud- 
den and  agonizing,  accompanied  by  extreme  dyspnoea, 
and  in  some  instances  are  fatal.  Relief  may  be  obtained 
by  inhalation  of  chloroform  or  nitrite  of  amyl,  or  by  an 
injection  of  morphine. 

Aneurism  is  disease  of  the  arterial  wall,  producing 
dilatation,  thus  forming  a  tumor  which  may  give  rise  to 
various  distressing  symptoms,  and  possibly  occasion  sud- 
den death  by  its  rupture.  It  is  treated  by  rest  and  re- 
stricted diet,  and,  if  accessible,  by  surgical  operation. 

Indigestion,  or  dyspepsia,  may  be  merely  a  slight 
functional  disorder,  or  a  symptom  of  serious  disease.  It 
is  variously  manifested.  There  may  be  pain,  nausea, 
regurgitation,  flatulence,  palpitation,  headache,  with 
constipation  or  diarrhoea,  and  numerous  other  minor 
symptoms,  all  more  or  less  associated  with  the  inception 
of  food.  Dyspeptics  are  notorious  for  constantly  study- 
ing their  symptoms.  Food  unsuitable  in  quality  or 
quantity  or  insufficiently  masticated  is  a  common  cause 
of  indigestion.  Overfatigue  often  produces  it,  and  alco- 
holism always.  No  general  rules  can  be  laid  down  for 
treatment,  as  what  suits  one  case  will  not  another.  It 
is  necessary  first  to  discover  the  cause  of  the  trouble. 
Good  sanitary  conditions,  regular  habits,  exercise,  and 
simple  food  are  always  important. 

Gastritis,  inflammation  of  the  lining  membrane  of 
the  stomach,  is  one  of  the  more  serious  troubles  marked 
by  chronic  dyspepsia.  The  symptoms  are  mainly  those 
of  indigestion,  with  acute  pain  and  tenderness  of  the 


314  A  TEXT-BOOK  OP  NURSING 

stomach.  Food,  especially  solid  food,  aggravates  the 
pain,  and  in  severe  cases  can  be  retained  only  in  the 
smallest  quantities.  Ulcers  of  the  stomach  may  develop, 
and  sometimes  perforation  takes  place,  producing  fatal 
termination.  Only  the  lightest  and  most  digestible 
foods  should  be  allowed — in  severe  cases  fluids  only;  or 
nourishment  by  the  stomach  may  be  entirely  suspend- 
ed and  nutrient  enemata  be  substituted.  Eest  is  im- 
portant. Counter-irritation  over  the  stomach  may  re- 
lieve the  pain  and  nausea. 

Peritonitis  follows  perforation  of  the  stomach  or 
bowels,  or  any  other  injury  of  the  membrane  covering 
the  intestines.  It  is  usually,  if  not  always,  of  septic 
origin,  and  is  a  very  dangerous  form  of  inflammation. 
There  is  acute  pain,  with  tenderness  over  the  abdomen, 
fever,  rapid,  wiry  pulse,  great  depression,  vomiting,  and 
constipation  with  tympanites.  There  may  be  retention 
or  suppression  of  urine.  Delirium  is  not  uncommon. 
The  patient  should  be  moved  as  little  as  possible,  and 
not  allowed  to  sit  up  for  any  purpose.  The  bedclothes 
may  be  lifted  from  the  abdomen  by  a  cradle,  and  any 
applications  ordered  must  be  made  as  light  as  possible. 
Hot  fomentations  may  be  helpful.  Nourishment  should 
be  given  in  strict  accordance  with  orders,  and  stimulants 
may  be  required.  It  is  now  customary  to  keep  the 
bowels  open  with  saline  cathartics,  and  to  withhold 
opium  as  much  as  possible. 

Appendicitis  is  an  inflammation  of  the  vermiform 
appendix,  usually  accompanied  by  more  or  less  peritoni- 
tis. The  symptoms  and  treatment  are  much  the  same. 
The  great  danger  to  be  feared  is  perforation. 

Typhlitis  is  an  inflammation  of  the  caecum,  occa- 
sionally leading  to  perforative  ulceration. 

Intestinal  obstruction  may  result  from  strangulated 


SPECIAL  MEDICAL  CASES  315 

hernia  or  other  causes,  and  unless  relieved  is  soon  fatal. 
Obstinate  constipation  is  present,  followed  by  stercora- 
ceous  vomiting,  abdominal  distention,  and  pain,  but 
usually  not  much  fever.  Make  hot  applications  ex- 
ternally, and  give  sips  of  hot  water  to  relieve  the  thirst 
and  vomiting,  but  little  if  any  food,  and  no  purga- 
tives. Get  advice  promptly,  as  early  abdominal  section 
may  be  the  only  hope. 

Dysentery  is  an  inflammation  of  the  mucous  mem- 
brane of  the  large  intestine.  It  may  be  preceded  by 
various  digestive  disorders,  abdominal  tenderness,  a 
sense  of  chilliness,  and  a  rise  of  temperature  at  evening. 
It  usually  begins  with  diarrhoea,  followed  by  tenesmus 
(which  is  the  characteristic  symptom),  griping  pain, 
and  discharge  of  mucus  from  the  bowel,  streaked  with 
blood,  and  lacking  the  healthy  fascal  odor.  Ventilate 
freely,  and  disinfect  the  stools.  Keep  the  patient  flat 
on  his  back,  warm,  and  quiet.  Put  a  broad  flannel 
bandage  around  the  abdomen.  Give  but  little  water. 
Feed  on  boiled  milk,  corn-starch,  rice-flour,  arrow-root, 
etc.,  *  not  very  hot.  The  inflammation  may  lead  to 
ulceration  or  sloughing  of  the  intestine,  and  death  from 
collapse. 

Chokra  morbus,  or  sporadic  cholera,  is  usually 
caused  by  indigestible  food  or  impure  water.  It  ex- 
hibits many  of  the  appearances  of  the  epidemic  disease, 
but  is  comparatively  harmless,  being  rarely  fatal,  except 
among  infants.  There  will  be  vomiting  and  purging, 
with  violent  intestinal  pain  and  cramps,  faintness,  and 
a  tendency  to  nervous  shock.  Encourage  rather  than 
check  the  clearing  out  of  the  system,  which  is  an  effort 
to  get  rid  of  some  irritating  matter,  apply  hot  poultices 
or  stupes  to  relieve  the  pain,  and  recovery  will  usually 
be  spontaneous.  Keep  the  extremities  warm,  and  stim- 


316  A  TEXT-BOOK  OF  NURSING 

ulate  moderately  if  required.  Give  but  little  and  light 
food,  only  gradually  returning  to  solid  diet. 

Intestinal  colic  is  most  commonly  caused  by  consti- 
pation and  flatulence.  The  pain  is  of  a  severe  and 
griping  character,  distinguished  from  that  of  peritonitis 
by  the  fact  that  it  is  relieved  by  pressure,  while  the  lat- 
ter is  increased  by  it.  The  characteristic  pulse  and  tem- 
perature of  peritonitis  are  absent.  A  clearing  out  of 
the  bowels,  which  is  most  safely  and  promptly  accom- 
plished by  enema,  will  usually  afford  entire  relief.  A 
hot  drink,  hot  applications  externally,  and  massage  of 
the  abdomen  may  be  helpful. 

Hepatic  colic  is  a  more  serious  trouble,  due  to  the 
presence  of  a  gall-stone  in  the  biliary  duct.  An  agoniz- 
ing pain  comes  on  in  the  upper  part  of  the  right  side  of 
the  abdomen  producing  nausea,  faintness,  and  profuse 
perspiration.  The  attack  will  only  subside  when  the 
obstructing  stone  passes  on  into  the  intestine;  hypo- 
dermic injections  of  morphine,  and  hot  fomentations 
sprinkled  with  laudanum  may  be  used  to  alleviate  the 
pain.  These  attacks  result  from  a  diseased  condition  of 
the  liver,  and  are  often  followed  by  jaundice.  This  is 
marked  by  a  yellow  tinge  of  the  skin  and  the  whites  of 
the  eyes,  while  the  bile  is  evident  in  the  urine  and  the 
perspiration,  but  conspicuously  absent  from  the  stools. 
Great  depression  of  spirits,  loss  of  appetite,  nausea,  and 
often  extreme  itching  of  the  skin  accompany  jaundice. 

Diabetes  mellitus  is  an  affection  characterized  by  an 
excessive  flow  of  urine  containing  glucose,  or  grape 
sugar,  an  ingredient  never  found  in  any  considerable 
quantity  during  health.  The  condition  comes  on  by  de- 
grees, is  more  frequent  among  men  than  women,  and 
at  middle  age,  although  children  are  subject  to  it.  The 
symptoms  are  extreme  thirst  and  abnormal  appetite, 


SPECIAL  MEDICAL  CASES  317 

especially  for  sweets,  but  loss  of  flesh  and  strength,  a 
dry  skin,  furred  tongue,  bad  breath,  and  intestinal  dis- 
orders. Is  most  alarming  when  complicated  by  lung 
troubles.  The  chief  treatment  is  by  dieting.  Every- 
thing containing  sugar,  or  starch,  convertible  into  it, 
should  be  prohibited.  The  doctor  will  give  you  a  list 
of  the  allowable  articles,  and  you  will  have  to  see  that 
your  patient  does  not  get  sugar  surreptitiously.  He 
should  have  regular  exercise,  and  take  special  care 
about  catching  cold.  The  disease  is  chronic  in  its 
course,  but  usually  terminates  fatally.  Injuries  and 
acute  diseases  are  more  than  ordinarily  dangerous  to  a 
diabetic  subject. 

"  Bright' s  disease  "  is  a  generic  term  including  sev- 
eral varieties  of  kidney  trouble,  presenting  albumin  in 
the  urine.  The  condition  described  as  acute  Bright's 
disease  commonly  results  from  taking  cold,  or  as  a 
sequel  of  scarlet  fever,  diphtheria,  or  rheumatism.  It 
not  infrequently  arises  during  pregnancy.  The  urine  is 
frequently  passed,  but  diminishes  in  quantity  and  be- 
comes albuminous,  often  containing  also  microscopic 
casts.  There  is  a  peculiar  waxy  complexion,  and  a  gen- 
eral dropsical  condition,  evident  at  first  about  the  eye- 
lids and  in  the  feet.  Headache,  gastric  disorders,  and 
general  debility  may  be  looked  for;  bronchitis  and 
heart-disease  are  frequent  complications.  Suppression 
of  urine  may  follow,  leading  to  death  by  uraemic  convul- 
sions or  coma,  or  the  disease  may  terminate  in  re- 
covery or  lapse  into  a  chronic  form.  The  danger  is 
great.  The  waste  product  must  in  some  way  be  carried 
off;  for  this  purpose  the  skin  is  excited  to  action,  the 
bowels  are  kept  open,  and  diluent  drinks  and  diuretics 
given.  Hot-air  baths  are  often  prescribed,  and  some- 
times a  skimmed-milk  diet.  Only  the  most  digestible 


318  A  TEXT-BOOK  OF  NURSING 

food  can  be  allowed,  and  that  must  be  given  with  the 
utmost  regularity. 

Renal  colic  has  symptoms  not  unlike  those  of  hepatic 
colic,  except  that  the  pain  takes  its  origin  in  the  kid- 
ney. It  is  usually  the  result  of  a  stone  in  the  kidney  or 
ureter.  The  urine  may  be  retained  or  discharged  fre- 
quently, a  few  drops  at  a  time.  It  often  contains  blood 
or  crystalline  deposits  of  diagnostic  value,  and  should 
always  be  saved  for  examination.  The  pain  can  only 
be  relieved  by  hypodermics  of  morphine.  Hot  applica- 
tions or  a  hot  bath  may  be  given.  Urinary  calculus  in 
the  bladder  may  be  treated  by  surgical  operation. 

The  skin,  like  the  other  organs,  is  liable  to  various 
diseases,  most  of  them  either  of  nervous  or  parasitic 
origin.  Those  of  the  latter  class  are  always  contagious. 

Erythema  is  the  name  given  to  an  inflammatory  con- 
dition of  the  skin  marked  by  redness,  with  slight  swell- 
ing, burning,  and  itching  sensations.  When  the  ery- 
thema is  general,  it  is  sometimes  called  "  rose  rash," 
and  bears  a  close  resemblance  to  the  rash  of  scarlet 
fever  or  measles,  for  which  it  is  often  mistaken.  It  is, 
however,  not  contagious  nor  serious,  though  uncomfort- 
able. It  may  be  the  result  of  indigestion  or  a  chill,  and 
is  often  associated  with  rheumatism.  A  warm  bath  and 
a  cathartic  will  hasten  its  disappearance.  Local  ery- 
thema is  usually  occasioned  by  some  irritant,  and  will 
subside  when  the  cause  is  removed.  The  itching  may 
be  allayed  by  a  solution  of  bicarbonate  of  soda  or  vase- 
line. 

Urticaria,  or  "  nettle  rash,"  shows  patches  of  white 
spots  on  a  red  ground  in  various  parts  of  the  body,  with 
severe  itching.  It  is  produced  by  irritation,  indigestible 
food  (in  some  people  by  fish  or  strawberries),  by  certain 
drugs,  and  even  occasionally  by  strong  emotion.  It  may 


SPECIAL  MEDICAL  CASES  319 

be  treated  by  the  application  of  tincture  of  benzoin, 
diluted  one  half.  Of  course,  the  exciting  cause,  if 
known,  must  be  removed. 

Eczema  is  a  form  of  eruption  less  transitory  and  far 
more  difficult  to  deal  with.  There  are  various  forms  of 
it,  acute  or  chronic.  The  most  characteristic  manifes- 
tation is  a  raw  surface  with  moist  exudation  from 
broken-down  vesicles,  more  or  less  covered  with  dry 
crusts.  Before  any  curative  treatment  will  be  of  serv- 
ice these  crusts  must  be  softened  with  oil  (vaseline  is 
the  best  to  use),  and  gently  removed.  The  part  affected 
may  then  be  cleaned  with  soft  potash  soap,  and  healing 
ointments  applied.  Washing  with  ordinary  soap  and 
water  should  be  avoided  as  well  as  scratching  or  any 
friction. 

Herpes  is  a  vesicular  eruption  of  which  there  are 
several  forms.  Herpes  zoster,  or  "  shingles,"  is  the  one 
most  generally  known.  This  appears  on  the  chest,  ex- 
tending just  half-way  round  from  the  spinal  column 
to  the  sternum,  and  is  almost  always  confined  to  one 
side.  The  eruption  is  preceded  by  pain  of  a  neuralgic 
character,  which  may  continue  even  for  some  little 
time  after  the  vesicles  have  disappeared.  Soothing 
applications  may  be  made,  but  the  disease  is  self-lim- 
ited, and  will  terminate  in  a  few  days  without  treat- 
ment. 

Scabies,  the  "  itch,"  is  due  to  a  small  animal  parasite 
which  burrows  under  the  skin  and  sets  up  a  peculiarly 
irritating  inflammation.  It  begins  usually  between  the 
fingers  and  toes,  but  may  spread  to  other  parts  of  the 
body  and  become  quite  general.  It  most  frequently 
occurs  in  children,  though,  not  limited  to  them.  It  is 
commonly  treated  with  ointments  of  sulphur.  It  is 
highly  contagious  and  persons  affected  with  it  should 


320  A  TEXT-BOOK  OF  NURSING 

be  isolated  until  it  is  cured,  and  their  clothing  should 
be  afterward  disinfected. 

Pediculi,  lice,  produce  a  papular  eruption  accom- 
panied by  constant  itching.  They  are  of  three  varieties 
— one  sort  peculiar  to  the  head,  one  to  the  hair  of  other 
parts,  and  a  third  which  infests  the  body  and  conceals 
itself  in  the  under-clothing.  The  usual  treatment  for 
them  all  is  with  mercurial  ointments,  but  there  is  some 
danger  attending  their  use.  Lice  can  not  live  in  any 
kind  of  grease.  Vaseline  liberally  applied  will  kill 
them,  and  is  a  simpler  and  safer  application,  especially 
fof  children.  The  nits,  or  eggs,  as  well  as  the  lice 
themselves,  must  be  thoroughly  cleaned  out  to  avoid  a 
return  of  the  trouble,  and  where  body  lice  are  found 
the  clothing  should  be  thoroughly  baked. 

Among  the  most  serious  affections  which  we  are 
liable  to  meet  are  diseases  of  the  brain  and  nervous 
system. 

Paralysis  occurs  in  several  forms.  Hemiplegia,  pa- 
ralysis of  the  lateral  half  of  the  body,  is  usually  the 
result  of  apoplexy — rupture  or  obstruction  of  some 
blood-vessel  in  the  brain.  A  person  in  apparently  good 
health  may  be  suddenly  attacked  with  pain  in  the  head, 
and  usually  loss  of  consciousness.  One  side  will  be 
found  helpless  and  without  sensation.  There  may  be 
gradual  restoration,  or  coma  and  death.  With  paralysis 
on  the  right  side  there  may  be  aphasia,  loss  of  the  power 
of  speech,  or  the  use  of  wrong  words.  Mental  confu- 
sion, lapsing  into  imbecility,  may  follow.  The  attacks 
tend  to  recur,  and  the  patient  rarely  survives  more 
than  two  or  three  of  them.  Paraplegia  is  paralysis  of 
the  lower  half  of  the  body  on  both  sides,  in  consequence 
of  injury  or  disease  of  the  spinal  cord.  There  will  be 
loss  of  voluntary  motion  and  sensation  below  the  point 


SPECIAL  MEDICAL  CASES  321 

affected,  and  loss  of  control  over  the  excretions.  Re- 
markable elevations  of  temperature  sometimes  occur, 
and  there  is  a  very  marked  tendency  to  the  formations 
of  bed-sores.  Complete  or  partial  recovery  may  take 
place,  but  more  often  there  is  a  gradual  spread  of  the 
inflammation,  resulting  fatally.  Neuritis  is  a  form  of 
paralysis  due  to  inflammation  of  the  spinal  nerves.  It 
may  be  a  consequence  of  chronic  alcoholism  or  lead 
poisoning  or  a  sequel  of  some  other  disease.  The  trou- 
ble comes  on  gradually,  commencing  with  pain  and  ten- 
derness in  the  limbs  with  increasing  loss  of  power  until 
a  condition  of  complete  helplessness  is  reached.  The 
intelligence  may  be  obscured,  the  appetite  and  diges- 
tion impaired.  Recovery  may  be  looked  for  if  treat- 
ment is  begun  sufficiently  early.  In  alcoholic  cases, 
total  abstinence  must  be  enforced.  Mental  derange- 
ment may  occur,  but  is  usually  only  temporary.  Liberal 
diet  is  important.  Massage  and  electricity  are  usually 
employed.  There  may  be  local  paralyses,  wasting  and 
failure  of  particular  groups  of  muscles  from  various 
causes,  most  often  treated  in  a  similar  way.  Paralyzed 
parts  must  be  kept  always  warm,  clean,  and  free  from 
pressure.  In  all  these  cases,  good  nursing  is  of  the  ut- 
most importance,  and  much  skill  as  well  as  infinite 
patience  is  called  for. 

Neuralgia  is  severe  and  paroxysmal  pain  in  a  nerve, 
unaccompanied  by  inflammation.  Hemicrania  and  sci- 
atica are  two  of  the  most  common  and  distressing  varie- 
ties of  it.  The  causes  are  numerous,  and  in  treatment 
must  first  be  considered.  The  general  state  of  the 
health  is  important,  neuralgia  being  most  frequent  in 
anasmic  subjects.  Local  applications  of  dry  heat  are 
perhaps  as  useful  as  any  general  remedy  that  can  be 
named. 


322  A  TEXT-BOOK  OP  NURSING 

Locomotor  ataxy  is  a  disease  of  the  spinal  cord,  dis- 
tinguished by  inability  to  control  the  movements  of  the 
legs  in  walking;  they  are  thrown  forward  in  a  peculiar 
jerky  way.  It  is  accompanied  by  severe  pain  in  the 
limbs  and  abdomen,  constipation,  and  bladder  troubles, 
often  impairment  of  sight  and  sensation.  The  disease 
comes  on  by  degrees,  and  is  chronic,  with  very  slow  im- 
provement, if  any.  Complete  cure  is  rare. 

Cerebral  meningitis  is  an  inflammation  of  the  mem- 
branes of  the  brain.  This  may  spread  from  disease  of 
adjoining  parts,  occur  as  a  complication  of  the  infec- 
tious fevers,  in  consequence  of  alcoholism,  tuberculosis, 
injuries  of  the  head,  or  other  causes.  The  leading  symp- 
toms are  high  fever,  violent  headache  with  intolerance 
of  light  and  noise,  vomiting,  obstinate  constipation,  ir- 
ritability, insomnia,  and  delirium,  often  terminated  by 
convulsive  attacks,  coma,  and  death.  Eecovery  may  be 
hoped  for,  except  in  the  tuberculous  form  of  the  dis- 
ease, but  all  inflammatory  affections  of  the  brain  are 
very  dangerous.  The  patient  should  be  kept  in  a  dark- 
ened room,  as  quiet,  cool,  and  free  from  excitement  as 
possible.  The  head  may  be  shaven,  and  ice-cold  appli- 
cations made  to  it.  Leeches  are  sometimes  employed. 
The  bowels  must  be  cleared  out.  Cold  fluid  food  may 
be  given.  Somewhat  similar  symptoms,  but  less  acute 
in  their  course,  may  be  occasioned  by  the  presence  of  a 
tumor  or  abscess  in  the  brain.  The  symptoms  in  both 
cases  are  variable  and  often  obscure. 

Chorea,  "  St.  Vitus's  dance,"  is  a  nervous  affection, 
occurring  most  frequently  in  young  girls,  sometimes 
brought  on  by  fright  or  excitement,  and  often  asso- 
ciated with  rheumatism.  It  is  characterized  by  lack  of 
control  of  the  muscular  movements,  affecting  one  or 
both  sides  of  the  body,  with  general  debility,  and  often 


SPECIAL  MEDICAL  CASES  323 

mental  weakness.  The  twitching  and  jerky  motions  are 
increased  by  any  excitement,  and  by  the  consciousness 
of  being  under  observation.  They  cease  during  sleep. 
In  young  persons  the  attacks  tend  to  recur,  but  the  dis- 
ease is  usually  curable.  In  adults  it  is  more  serious; 
the  severe  attacks  may  lead  to  a  condition  of  mania, 
or  terminate  in  death  from  exhaustion.  Bed-sores  are  a 
common  complication.  Complete  rest  and  nourishing 
food  are  essential  in  the  treatment.  Laxatives  may  be 
needed — there  is  usually  a  disordered  condition  of  the 
stomach  and  bowels — and  tonics  are  thought  useful. 

Hysteria  is  the  name  given  to  a  disordered  state  of 
the  nervous  system,  more  common  in  women  than  in 
men,  though  not  entirely  confined  to  them.  It  is  often 
associated  with  ovarian  or  uterine  troubles.  Hysterical 
phenomena  are  infinitely  varied.  There  is  scarcely  any 
disease  the  symptoms  of  which  it  may  not  simulate. 
The  patient  is  morbidly  emotional,  and  exaggerates  her 
symptoms  more  or  less  intentionally,  but  it  should  be 
remembered  that  at  the  basis  of  all  the  imaginative  and 
simulated  manifestations  is  a  real,  though  perhaps  ob- 
scure, malady.  Hysteria  is  not,  as  sometimes  appears, 
imposition  pure  and  simple,  but  the  patient  is  to  some 
extent  irresponsible  from  defective  will-power.  It  may 
lead  to  the  verge  of  insanity.  There  are  two  forms,  the 
one  continuous,  the  other  paroxysmal.  Common  symp- 
toms are  a  sensation  as  of  a  ball  in  the  throat,  a  dry 
cough,  very  abundant  and  light-colored  urine,  flatulence 
and  borborygmi.  Neuralgia,  local  paralyses,  rigid  con- 
tractions of  joints,  and  loss  of  voice  sometimes  occur. 
Hygienic  treatment  is  of  great  importance,  exercise, 
healthful  food,  and  regular  habits  being  more  impor- 
tant than  medical  treatment.  Narcotics  and  stimulants 
should  especially  be  avoided.  Hysterical  fits  need  no 


324:  A  TEXT-BOOK  OP  NURSING 

treatment,  and  will  terminate  more  quickly  without  it. 
The  patient  never  hurts  herself  if  left  alone. 

All  neurasthenic  patients  make  heavy  demands  upon 
a  nurse,  and  they  are  often  very  trying  cases  to  deal 
with.  Various  phases  and  degrees  of  nervous  exhaus- 
tion are  met  with.  Many  cases  have  been  successfully 
treated  without  medicine — by  rest,  seclusion,  dieting, 
together  with  massage,  electricity,  and  sponge  baths; 
but  for  this  a  nurse  needs  special  experience.  No  one 
should  undertake  to  practice  massage  without  having 
received  thorough  instruction,  still  less  to  give  elec- 
tricity unless  as  distinctly  directed.  That  the  doctor 
will  occasionally  leave  the  manipulation  of  a  battery  to 
an  intelligent  nurse  does  not  qualify  her  to  set  up  as  an 
electrician.  Electricity  is  a  powerful  agent,  requiring 
the  greatest  care  in  its  management. 

Insanity  includes  various  forms  of  mental  unsound- 
ness,  from  acute  mania  and  melancholia  to  dementia, 
idiocy,  and  imbecility.  The  care  of  insane  patients  re- 
quires special  training,  added  to  much  tact  and  good 
judgment.  With  a  patient  of  unsound  mind  it  is  never 
safe  to  be  off  one's  guard  for  an  instant,  but  there  should 
be  as  much  freedom  from  restraint  as  is  compatible 
with  safety.  Delusions  and  hallucinations  of  all  kinds 
are  met  with  which  can  never  be  argued  away,  and  need 
to  be  judiciously  treated.  The  care  of  such  patients  is 
very  different  from  ordinary  sick-nursing,  and  is  best 
provided  for  in  a  suitable  institution. 

Delirium  is  a  temporary  mental  aberration  occur- 
ring in  the  course  of  fevers  and  exhausting  diseases. 
It  is  apt  to  come  on  or  be  increased  at  night.  Delirium 
may  be  quiet,  or  active  and  violent.  The  delusions,  like 
those  of  the  insane,  should  be  as  far  as  possible  hu- 
mored. Opposition  only  irritates  and  does  harm.  The 


SPECIAL  MEDICAL  CASES  325 

nurse  must  be  invariably  kind  and  gentle,  but  at  the 
same  time  firm  and  vigilant.  In  violent  delirium  re- 
straint must  be  effectual,  or  it  only  aggravates  the  trou- 
ble. A  dry  sheet  put  on  like  a  pack  will  take  the  place 
of  a  straight- jacket  if  needed,  but  with  proper  attend- 
ance physical  restraint  is  seldom  necessary,  and  should 
be  avoided  when  possible.  Avoid  every  appearance  of 
fear;  keep  the  room  quiet  and  dark. 

Delirium  tremens  is  a  peculiar  type,  the  result  of 
chronic  alcoholic  poisoning.  It  is  marked  by  a  nervous 
tremor,  great  anxiety  and  restlessness,  and  horrible  hal- 
lucinations. Insomnia  and  suicidal  mania  are  common. 
The  pulse  is  feeble,  the  skin  cold,  and  often  bathed  in 
perspiration,  the  pupils  minutely  contracted,  but  with 
no  intolerance  of  light.  The  nervous  prostration  and 
inability  to  take  food  may  become  extreme,  and  the  case 
may  end  fatally,  or  it  may  terminate  with  profound 
sleep  and  spontaneous  recovery.  Sleep  must  somehow 
be  induced;  the  bowels  must  be  kept  open,  and  nourish- 
ing food  given,  even  if  by  force. 

Diphtheria  is  a  form  of  blood-poisoning,  often  re- 
sulting from  imperfect  sewerage.  It  is  first  manifested 
by  feverishness,  symptoms  of  a  cold,  difficulty  in  swal- 
lowing, and  swelling  of  the  tonsils,  followed  by  an  exu- 
dation of  false  membrane  'in  white  patches  on  the 
throat.  The  discharge  from  the  mouth  and  nostrils  is 
likely  to  be  abundant;  it  should  be  wiped  away  on  soft 
cloths,  which  are  immediately  burned,  as  it  is  highly 
infectious.  Take  every  precaution  against  infection, 
and  follow  all  orders  to  the  letter.  Give  plenty  of  fluid 
nourishment.  Nutritive  enemata  may  be  necessary. 
The  patient  may  be  choked  by  the  obstruction  of  the 
throat,  but  there  is  equal  danger  of  paralysis  of  the 
heart,  which  may  occasion  a  fatal  termination,  even 
22 


326  A  TEXT-BOOK  OF  NURSING    . 

after  convalescence  from  the  disease  is  well  established. 
The  horizontal  position  must  be  maintained  for  a  long 
while.  Tracheotomy  is  sometimes  resorted  to,  but  there 
is  danger  that  the  membrane  will  continue  to  form  be- 
low the  point  of  incision.  Intubation  is  considered 
preferable.  These  cases  are  now  much  treated  by  the 
hypodermic  injection  of  antitoxin,  an  attenuated  diph- 
theria culture  most  effective  when  given  in  the  in- 
cipient stages  of  the  disease.  The  part  into  which  the 
injection  is  to  be  made  should  be  first  scrubbed  with 
green  soap  and  water,  followed  by  alcohol,  and  the 
syringe  itself  sterilized  by  boiling  for  ten  minutes  just 
before  using.  A  rise  of  temperature  immediately  fol- 
lowing this  treatment,  need  not  occasion  special 
anxiety. 

Asiatic  cholera  is  a  specific  infectious  disease,  com- 
municable by  means  of  the  excreta.  It  is  characterized 
by  violent  vomiting  and  purging,  with  so-called  "  rice- 
water  evacuations,"  cramps,  extreme  prostration,  and 
collapse.  It  usually  commences  with  slight  diarrhoea 
and  nausea,  and,  wherever  the  disease  prevails  as  an 
epidemic,  these  symptoms  should  receive  prompt  atten- 
tion. If  it  progresses,  there  is  intense  thirst,  restless- 
ness and  muscular  spasm,  the  pulse  becomes  rapid  and 
weak,  the  temperature  falls  below  normal,  the  skin  be- 
comes livid,  the  eyeballs  sunken,  and  a  generally  ghast- 
ly appearanqe  precedes  death  by  collapse.  The  mind  is 
usually  clear  to  the  last.  The  first  endeavor  is  to  con- 
trol the  purging,  for  which  opium  is  usually  given. 
Keep  the  patient  in  bed  and  warm.  In  all  cases  of 
diarrhoea,  especially  in  cholera,  insist  on  the  recumbent 
position.  Give  ice  ad  lib.,  but  little  water ;  food  strictly 
as  directed.  Nutritive  enemata  may  be  necessary.  The 
stools,  vomited  matter,  and  urine  must  be  disinfected 


SPECIAL  MEDICAL  CASES  327 

most  thoroughly  and  disposed  of  promptly,  and  all  pos- 
sible precautions  taken  against  the  spread  of  the  disease. 

Typhoid,  or  enteric,  fever  is  due  to  a  specific  germ 
associated  with  certain  forms  of  decomposing  animal 
matter,  and  is  characterized  by  a  catarrhal  inflamma- 
tion of  the  mucous  membrane  of  the  small  intestine, 
with  ulceration  in  certain  spots,  called  "  Peyer's 
patches."  It  is  most  common  in  early  adult  life,  and 
during  the  latter  part  of  the  year.  It  may  occur  as  an 
epidemic,  in  which  case  there  is  some  common  cause  to 
be  looked  for  and  remedied,  most  often  impure  drink- 
ing-water. The  period  of  incubation  is  from  two  to 
three  weeks,  the  usual  duration  from  three  to  four 
weeks,  dating  from  the  first  rise  of  temperature. 

The  attack  most  often  comes  on  gradually,  begin- 
ning with  dull  headache,  loss  of  appetite,  general  ma- 
laise, sometimes  nausea  and  slight  diarrhoea,  and  nose- 
bleed. The  patient  may  not  go  to  bed  till  the  fifth  or 
sixth  day,  though  the  fever  steadily  increases  during 
the  first  week,  having  a  remittent  type,  falling  in  the 
morning,  but  rising  every  night  a  little  higher,  till  it 
gets  up  to  103°  or  104°.  By  this  time  there  is  violent 
headache,  intolerance  of  light,  and,  perhaps,  slight  de- 
lirium, parched  lips  and  tongue,  abdominal  tenderness 
and  tympanites.  During  the  second  week  the  fever  re- 
mains continuously  high,  and  an  eruption  of  rose-col- 
ored spots  may  appear  on  the  abdomen  and  chest.  These 
are  slightly  elevated,  and  disappear  upon  pressure,  to 
return  again  immediately.  Each  spot  remains  visible 
for  three  days.  Successive  crops  may  appear  for  ten 
or  twelve  days.  The  headache  is  less  during  the  second 
week,  the  bowels  are  likely  to  be  relaxed,  the  motions 
of  a  light  ochre  or  "  pea-soup  "  color.  In  severe  cases, 
the  patient  assumes  a  characteristic  typhoid  appear- 


328  A  TEXT-BOOK  OF  NURSING 

ance,  the  face  dusky  and  indifferent,  the  muscular  pros- 
tration evidently  extreme,  the  mental  condition  one  of 
stupor,  varied  by  active  delirium.  The  tongue  is  brown, 
dry,  and  heavily  coated;  sordes  collect  on  the  teeth. 
During  the  third  week  the  fever  again  becomes  remit- 
tent, falling  toward  morning,  though  rising  at  night. 
The  general  typhoid  condition  deepens,  the  pulse  be- 
comes frequent  and  feeble,  the  emaciation  and  loss  of 
strength  rapid.  This  is  the  period  of  greatest  danger. 
By  the  beginning  of  the  fourth  week  there  should  be 
evident  improvement,  the  fever  becoming  intermittent, 
and  the  evening  exacerbations  decreasing,  the  tongue 
clearing  off,  and  the  tympanites  disappearing.  There 
will  now  be  a  return  of  the  appetite  and  natural  sleep. 
Constipation  is  common.  When  the  temperature  keeps 
a  steady  normal,  convalescence  may  be  regarded  as  fully 
established.  The  strength  begins  to  return,  and  the 
appetite  becomes  sharp.  Convalescence  is  always  slow, 
and  likely  to  be  complicated.  There  may  be  relapses, 
usually  milder  than  the  original  attack,  and  of  shorter 
duration,  but  running  a  similar  course.  The  greatest 
danger  in  typhoid  is  that  of  perforation  of  the  bowel 
by  the  intestinal  ulcers,  and  consequent  acute  peritoni- 
tis. The  symptoms  of  perforation  are  severe  pain,  in- 
creased by  pressure,  rapid  distention  of  the  abdomen, 
rapid,  feeble  pulse,  and  other  signs  of  collapse.  It  is 
usually  fatal  within  twenty-four  hours.  Intestinal 
hasmorrhage  may  occur  without  perforation,  from  the 
rupture  of  an  artery  in  some  ulcer.  It  is  usually  pre- 
ceded by  a  sudden  fall  in  temperature.  It  may  be  seri- 
ous enough  to  be  fatal,  without  any  external  escape  of 
blood.  The  treatment  consists  in  absolute  rest,  the 
application  of  an  ice-bag  to  the  abdomen,  and  semi- 
narcosis  by  opium. 


SPECIAL  MEDICAL  CASES  329 

In  no  case  is  good  nursing  of  more  vital  importance 
than  in  typhoid  fever.  There  must  be  constant  watch- 
fulness and  care  from  the  beginning  until  complete  re- 
covery. The  recumbent  posture  must  be  strictly  main- 
tained until  the  intestinal  ulcers  are  perfectly  healed. 
The  diet  must  be  rigidly  in  accordance  with  the  doctor's 
directions,  even  after  the  patient  feels  quite  well. 
Many  deaths  occur  from  indiscretion  or  overexertion 
during  convalescence.  There  is  no  specific  treatment; 
little  medicine  will  be  given;  everything  depends  upon 
hygienic  precautions  and  economizing  the  patient's 
strength  until  the  disease  is  exhausted.  The  patient 
must  be  kept  clean  and  dry — there  is  great  danger  of 
bed-sores  with  the  extreme  emaciation — but  in  no  way 
fatigued.  Wash  the  mouth  and  teeth  several  times 
daily,  and  give  cold  water  in  small  quantities  even  if  not 
asked  for.  Keep  the  temperature  of  the  room  low  while 
the  fever  is  high.  The  stools  need  to  be  disinfected 
with  the  same  care  as  those  of  cholera,  for  the  poison 
passes  out  in  them,  and  is  readily  communicable. 

Typhus  fever  resembles  typhoid  only  in  name.  It  is 
a  highly  contagious  disease,  associated  with  overcrowd- 
ing and  bad  ventilation.  The  attack  is  usually  abrupt, 
beginning  with  a  chill,  followed  by  a  temperature  of 
105°  Fahr.  or  more,  with  violent  headache  and  extreme 
prostration.  The  rash  appears  toward  the  end  of  the 
first  week,  showing  first  on  the  sides  of  the  abdomen  in 
dirty-pink  or  purplish  spots.  When  abundant,  it  is  de- 
scribed as  "  mulberry  rash."  Each  spot  persists  until 
the  disease  terminates  in  convalescence  or  death.  The 
head  is  much  affected;  violent  delirium  occurs,  or  in 
some  cases  coma-vigil.  The  disease,  unless  it  termi- 
nates fatally,  usually  runs  for  fourteen  days,  after 
which  the  amendment  will  be  abrupt,  as  was  the  onset. 


330  A  TEXT-BOOK  OF  NURSING 

Eelapges  are  rare.  The  patient's  strength  must  be 
saved  in  every  possible  way,  the  aim  being  to  sustain 
the  vital  powers  until  the  fever  abates.  Watch  every 
moment  during  the  delirium.  Keep  ice-bags  on  the 
head.  The  sleeplessness  must  be  relieved,  and  nourish- 
ment must  be  given,  if  by  force.  Quarantine  strictly. 
Ventilation  is  especially  important,  as  the  poison  is 
thrown  off  most  virulently  from  the  lungs  and  skin. 
Fresh  air  is  the  best  remedy,  regardless  of  cold. 

Scarlet  fever  has  a  period  of  incubation  anywhere 
from  two  to  ten  days.  It  begins  with  headache,  nausea, 
sore  throat,  pains  in  the  limbs,  rapid  pulse,  and  rise  of 
temperature,  more  rarely  with  chills  or  convulsions. 
The  eruption  generally  appears  on  the  second  day — 
rarely  later — beginning  on  the  chest,  a  bright  efflores- 
cence, rendered  pale  by  pressure,  but  immediately  re- 
turning. It  is  most  distinct  on  the  back  and  at  the 
bends  of  the  joints.  The  danger  is  somewhat  propor- 
tionate to  the  darkness  of  the  eruption,  but  there  is  a 
very  malignant  variety,  rapidly  fatal,  with  no  eruption 
at  all.  The  rash  lasts  from  four  to  six  days,  and  as  it 
declines  desquamation  sets  in.  This  is  the  most  infec- 
tious period,  and  the  isolation  must  be  complete  until 
it  is  fully  over,  and  even  for  a  week  later.  The  most 
severe  cases  may  follow  exposure  to  a  light  one.  With 
high  fever  may  be  the  characteristic  "  strawberry 
tongue  "  and  sore  throat,  occasioning  difficulty  in  swal- 
lowing. The  tonsils  sometimes  ulcerate.  Hot  appli- 
cations about  the  throat  may  relieve  it.  Various  com- 
plicationi  are  common,  and  there  is  no  disease  in  which 
thert  is  greater  liability  to  troublesome  gequelffi.  Kid- 
ney troubles,* rheumatism,  diphtheria,  inflammation  of 
the  points,  and  deafness  from  the  ulcersttion  extending 
into  the  Eustachian  tubes,  are  all  likely  to  attend  or 


SPECIAL  MEDICAL  CASES  331 

follow  it.  The  greatest  care  should  be  taken  not  to 
let  th«  patient  get  chilled  during  convalescence;  the 
skin  is -especially  sensitive  while  desquamation  is  going 
on,  and  if  its  action  is  suddenly  checked,  the  extra  work 
thrown  on  the  kidneys  is  almost  sure  to  induce  conges- 
tion of  those  organs.  Even  the  lightest  cases  should 
be  kept  in  bed,  and  protected  from  the  least  exposure. 
However  well  the  patient  may  appear,  'watch  the  urine 
carefully,  and  test  it  now  and  then  for  albumin.  Should 
it  become  scanty,  smoky,  or  contain  a  trace  of  albumin, 
it  is  an  indication  of  danger.  Note  whether  the  eyelids 
or  limbs  swell,  and  if  there  is  any  difficulty  in  breath- 
ing. If  diphtheritic  trouble  is  impending,  there  is  likely 
to  be  free  discharge  from  the  nose.  Very  little  medica- 
tion is  now  employed  for  these  cas.es.  Keep  up  good 
sanitary  conditions,  fresh  but  not  cold  air,  food  as  di- 
rected. Cold  water  may  be  given  freely.  During  des- 
quamation, the  body  may  be  sponged  off  frequently  with 
tepid  or  warm  water,  and  rubbed  with  carbolized  vase- 
line or  cacao-butter  to  allay  the  irritation.  Scarlatina 
is  not,  as  commonly  supposed,  a  lighter  form  of  the 
disease,  but  merely  its  Latin  name. 

Small-pox,  or  variola,  begins  with  great  severity 
from  nine  to  fourteen  days  after  exposure,  usually  with 
a  chill,  followed  by  high  temperature,  rapid  pulse,  gen- 
eral feeling  of  lassitude,  severe  pains' in  the  back  and 
legs,  vomiting,  sore  throat,  tongue  white  and  furred. 
The  rash  appears  on  the  third  day,  in  small  spots  like 
flea-bites,  first  on  the  face  and  neck,  along  the  edges 
of  the  hair,  then  extending  downward.  When  the  rash 
comes  out  the  febrile  symptoms  subside.  The  pimples 
become  vesicular,  showing  a  depression  in  the  center, 
and  about  the  fifth  or  sixth  day  suppurate.  With  the 
suppuration  the  high  fever  returns,  often  preceded  by 


332  A  TEXT-BOOK  OP  NURSING 

a  chill.  The  vesicles  have  a  marked  and  characteristic 
odor.  They  increase  in  size,  and  may  become  confluent, 
running  together,  or  remain  discrete,  distinct.  The 
confluent  variety  is  by  far  the  most  dangerous.  By 
the  ninth  day  they  reach  their  full  size  and  burst,  or 
crust  over,  and  desiccate.  The  secondary  fever  then 
subsides,  and  convalescence  is  established.  Another 
high  rise  of  temperature  would  be  suggestive  of  some 
complication.  The  danger  in  small-pox  is  greatest  at 
the  beginning  of  the  suppurative  fever.  The  more 
abundant  the  eruption,  the  greater  the  danger.  The 
pain  attending  the  eruption  may  be  relieved  by  hot 
fomentations.  When  the  vesicles  begin  to  be  prom- 
inent, they  may  be  pricked  and  bathed  with  some  weak 
disinfectant  solution.  On  the  palms  and  soles,  where 
the  skin  is  thick,  they  should  be  opened  early.  During 
desiccation,  sponge  with  warm  water  and  oil  the  sur- 
face freely.  Ventilate  well.  Keep  the  room  dark,  and 
its  temperature  dpwn  to  60°.  If  there  is  delirium,  ap- 
ply ice  to  the  head.  Children  must  be  kept  in  gloves. 
The  throat  may  be  so  inflamed  as  to  render  swallow- 
ing difficult.  But  try  to  keep  the  patient's  strength  up, 
and  his  temperature  down,  and  isolate  completely.  He 
must  not  come  in  contact  with  others  till  every  trace 
of  a  scab  has  disappeared.  Infection  may  take  place 
during  any  stage,  even  that  of  incubation.  Varioloid, 
a  modified  form,  may  result  from  exposure  after  vacci- 
nation, running  a  similar  course,  but  milder,  and  of 
briefer  duration. 

Vaccination,  properly  performed,  renders  one  im- 
mune to  this  poison,  for  a  time  at  least.  It  consists  in 
introducing  into  the  circulation  lymph  taken  from  the 
udder  of  a  cow  which  has  been  inoculated  with  the  dis- 
ease. This  attenuated  culture  produces  in  a  suscep- 


SPECIAL  MEDICAL  CASES  333 

tible  subject  a  mild  type  termed  vaccinia,  which  pro- 
tects against  the  more  virulent  infection.  The  opera- 
tion is  in  itself  simple,  and  a  nurse  might  easily  perform 
it,  but  it  involves  a  responsibility  which  she  will  be 
wiser  not  to  assume,  owing  to  the  risk  of  introducing 
into  the  system  other  germs  than  those  of  the  vaccine 
virus.  Very  ill  effects  have  been  known  to  follow  the 
use  of  an  imperfectly  sterilized  preparation. 

The  lymph  now  comes  put  up  in  sealed  tubes  of 
gelatine,  in  which  medium  the  vaccine  germs  retain 
their  vitality  after  others  have  become  inert.  This  is 
well  rubbed  into  a  spot  previously  scrubbed  and  scraped 
till  the  serum  exudes,  left  exposed  to  the  air  till  it  dries, 
and  then  covered,  preferably  by  a  light  bandage.  After 
the  usual  period  of  incubation,  mild  constitutional 
symptoms  may  be  expected  to  appear,  and  the  spot 
treated  to  develop  a  typical  pustule.  This  should  be 
protected  from  friction  until  the  scab  separates,  a 
variable  time.  This  scab  should  be  burned,  as  also  band- 
ages soiled  from  the  discharging  pustule. 

Malarial,  or  intermittent,  fever  is  a  non-infectious 
fever  of  an  endemic  type,  usually  originating  in  marshy 
regions.  The  most  common  form  of  attack  exhibits 
three  stages.  The  patient  is  first  seized  with  a  chill, 
more  or  less  violent  and  prolonged,  during  which, 
though  he  feels  cold,  his  temperature  will  be  found  to 
be  rapidly  rising.  Severe  headache,  nausea,  and  pains 
in  the  limbs  often  occur.  The  feeling  of  chilliness 
passes  away,  and  is  succeeded  by  a  hot  stage.  The  tem- 
perature keeps  up,  the  face  is  flushed,  the  skin  hot  and 
dry.  Finally,  perhaps  after  several  hours,  profuse 
sweating  ensues,  during  which  the  temperature  falls 
and  the  other  acute  symptoms  subside.  These  attacks 
occur  periodically,  with  intervals  of  fairly  good  health. 


334:  A  TEXT-BOOK  OF  NURSING 

Constitutional  treatment  is  called  for,  and  sometimes 
change  of  climate.  During  the  chills  the  nurse  can  do 
something  to  alleviate  the  discomfort  by  the  use  of 
warm  blankets,  hot  bottles,  etc.,  and  during  the  fever 
by  tepid  sponging  and  cooling  drinks. 

Inflammatory  rheumatism,  or  acute  rheumatic  fever, 
usually  results  from  exposure  to  cold  and  damp.  It 
may  possibly,  when  latent  in  the  system,  be  developed 
by  malarial  poisoning.  The  fever  often  runs  high  be- 
fore the  local  symptoms  appear.  These  are  heat,  red- 
ness, swelling,  and  intense  pain  in  one  or  more  joints, 
having  a  tendency  to  shift  about  from  one  spot  to  an- 
other. There  is  profuse  perspiration,  having  a  charac- 
teristic odor.  The  urine  is  likely  to  be  scanty,  high 
colored,  and  strongly  acid.  Nervous  disorders  and  mild 
delirium  at  night  may  accompany  severe  cases.  The 
greatest  danger  is  of  cardiac  complication.  A  horizontal 
position  should  be  maintained,  and  the  patient  lifted  as 
little  as  possible,  as  the  slightest  motion  is  agonizing. 
He  should  be  kept  warmly  dressed  in  flannel.  The 
bowels  should  be  kept  open,  and  only  light  and  digesti- 
ble food  given.  Avoid  all  excitement,  and  in  no  case 
give  stimulants  except  under  the  doctor's  direction. 

In  giving  stimulants  in  fevers,  note  the  following 
points:  If,  after  taking,  the  tongue  and  skin  become 
moist,  the  pulse  steadier,  the  breathing  more  tranquil, 
if  delirium  is  quieted,  and  sleep  induced,  they  may  be 
recognized  as  helpful,  and  their  use  continued  if  called 
for.  If  the  reverse  effects  follow,  the  skin  and  tongue 
becoming  dry,  the  pulse  quicker,  the  breathing  hurried, 
they  are  doing  harm,  and  should  be  stopped. 

"  Be  strong  and  do  your  best, 
With  honest  heart  and  childlike  faith 
That  God  will  do  the  rest." 


CHAPTER   XIX 

"  But  how  much  unexpected,  by  so  much 
We  must  awake  endeavor  for  defense, 
For  courage  mounteth  with  occasion." 

Shakespeare. 

SOME  exceptional  cases  will  arise,  in  which  whatever 
is  to  be  done  must  be  done  at  once,  without  waiting  for 
the  arrival  of  skilled  service,  and  in  these  emergencies, 
if  a  nurse  is  present,  she  will  naturally  be  looked  to  in 
the  place  of  a  doctor.  How  much  the  nurse  is  justified 
in  doing,  it  is  difficult  to  say;  it  depends  upon  the  case 
and  upon  the  nurse.  You  will  not  wish  to  assume  re- 
sponsibilities that  do  not  belong  to  you,  but,  when  a 
doctor  can  not  be  at  once  obtained,  prompt  action  on 
your  part  may  save  life.  Do  not  try  intricate  experi- 
ments. Eemember  that  the  simplest  things  are  often 
the  most  useful,  and  that  it  is  usually  safer  to  do  too 
little  than  too  much.  As  a  rule,  if  you  do  not  feel  sure 
what  ought  to  be  done,  do  nothing.  But  if  you  have 
made  any  use  of  your  opportunities,  you  will  know  at 
least  more  than  the  utterly  uninstructed  crowd.  Now 
is  a  chance  to  practice  the  coolness  and  presence  of 
mind  which  your  training  has  led  you  to  cultivate. 
Above  all  things  do  not  get  excited,  or  you  will  forget 
all  that  you  would  otherwise  know. 

In  case  of  any  accident,  send  a  written  message  to 
the  doctor,  describing  as  well  as  you  can  the  nature  and 
urgency  of  the  case,  so  that  he  may  come  prepared  with 

335 


336  A  TEXT-BOOK  OF  NURSING 

the  necessary  appliances.  A  verbal  message  sent  by  an 
excited  bystander  is  never  delivered  intelligently.  Try 
to  get  rid  of  everybody  who  can  not  be  made  useful, 
so  as  to  secure  plenty  of  fresh  air  and  room  to  work. 
If  respiration  is  suspended,  or  the  danger  imminent, 
treatment  must  be  begun  at  once,  on  the  spot,  without 
loss  of  time;  otherwise  the  patient  may  be  carried  to 
the  nearest  convenient  house.  For  this  purpose,  a 
stretcher,  or  something  which  will  take  its  place,  on 
which  he  can  lie  horizontally,  should  be  provided.  The 
bearers  should  be  instructed  to  carry  it  in  the  hands, 
not  on  the  shoulders,  and  to  avoid  unnecessary  jolting. 
It  is  better  for  them  not  to  keep  step. 

Have  a  warm  bed  ready  to  put  him  in.  Eemove  the 
clothes  with  as  little  disturbance  as  may  be,  and  do  not 
cut  anything  that  can  readily  be  ripped.  If  a  foot  is 
hurt,  the  shoe  and  stocking  will  generally  have  to  be 
sacrificed,  but  almost  everything  else  can  be  ripped 
without  ruining.  Take  the  clothes  from  the  sound  side 
first,  but  in  putting  on  a  garment  begin  with  the  in- 
jured side.  Special  directions  for  undressing  a  woman 
are  hardly  needed;  in  case  of  a  man,  remember  to  un- 
fasten the  suspenders  behind  as  well  as  in  front.  All 
the  clothing  can  then  be  easily  removed  under  cover  of 
a  sheet. 

Severe  injury  of  any  kind  may  be  followed  by  that 
complete  prostration  of  the  vital  powers  known  as 
shock.  The  patient  lies  in  an  apathetic  state,  though 
not  unconscious,  the  surface  of  the  body  pale  and  cov- 
ered with  cold  perspiration.  There  will  be  an  abnor- 
mally low  temperature,  weak  and  irregular  pulse  and 
respiration,  dilated  nostrils,  drooping  lids,  with  eyes 
dull  and  sunken,  mental  and  muscular  weakness,  and, 
in  less  severe  cases,  nausea  and  vomiting  are  present. 


EMERGENCIES,   SURGICAL  AND  MEDICAL     337 

Death  may  be  caused  indirectly  by  failure  to  rally  from 
this  condition.  Lay  the  patient  on  his  back,  the  head 
low,  and  give  stimulants  till  the  heart's  action  is  re- 
vived. Loosen  all  clothing.  Apply  heat  to  the  extremi- 
ties by  means  of  hot  water  bottles,  hot  flatirons,  or 
bricks,  and  put  a  hot  plate  covered  with  a  towel  over 
the  epigastrium.  Rub  with  a  hot  flannel  to  stimulate 
the  circulation.  Hot  tea,  coffee,  or  beef-tea  may  be 
given  if  it  can  be  retained.  When  there  is  nausea, 
brandy  is  the  best  form  of  stimulant.  If  the  patient 
can  not  swallow,  inject  brandy  or  whisky  well  up  into 
the  rectum,  a  teaspoonful  at  a  time,  diluted  with  four 
or  five  of  warm  milk  or  water.  This  may  be  repeated 
every  twenty  minutes  until  the  patient  shows  signs  of 
improvement. 

Syncope,  or  fainting,  manifests  many  of  the  same 
signs  as  shock,  and  mild  forms  of  the  latter  are  often 
confounded  with  it.  There  is  unconsciousness,  occa- 
sioned by  an  insufficient  supply  of  blood  to  the  brain. 
Do  not  raise  the  head;  keep  it  as  low  as,  or  lower  than, 
the  feet;  this  position  alone,  with  plenty  of  fresh  air, 
will  often  restore  consciousness.  If  the  condition  per- 
sists, proceed  as  in  case  of  shock.  Ammonia  may  be 
given  by  inhalation,  but  not  too  strong,  as  the  irritation 
may  occasion  dangerous  bronchitis.  Sprinkle  the  face 
sharply  with  cold  wtaer.  In  either  case,  bind  up  broken 
bones,  dress  wounds,  and  control  haemorrhage  before 
making  efforts  to  revive  the  patient. 

Haemorrhage  is  the  escape  of  blood  from  its  contain- 
ing vessels.  According  to  the  kind  of  vessel  ruptured, 
it  may  be  described  as  arterial,  venous,  or  capillary 
haemorrhage.  It  is  usually  easy  to  distinguish  these. 
Blood  from  an  artery  will  be  of  a  bright-red  color,  and 
will  spurt  out  in  jets  of  considerable  force  from  the  side 


338  A  TEXT-BOOK  OF  NURSING 

of  the  wound  nearest  the  heart.  The  jets  will  corre- 
spond to  the  beats  of  the  heart,  not  entirely  intermit- 
ting, but  subsiding  into  a  steady  flow  between  them. 
Venous  blood  is  of  a  dark-purplish  hue,  and  moves  in 
a  sluggish  continuous  flow,  mainly  from  the  side  farthest 
from  the  heart.  Capillary  haemorrhage  is  a  mere  oozing 
of  blood.  The  first  is  by  far  the  most  dangerous.  Haem- 
orrhage from  a  large  artery,  if  not  promptly  checked, 
may  prove  fatal  in  a  few  moments. 

All  wounds  are  attended  by  more  or  less  bleeding. 
Besides  such,  described  as  traumatic,  there  may  be  haem- 
orrhage caused  by  rupture  of  the  blood-vessels,  either 
from  disease  of  their  coats  or  of  surrounding  parts. 
Haemorrhage  following  shortly  after  an  operation,  when 
it  has  been  once  completely  checked,  is  known  as  sec- 
ondary. It  arises  either  from  giving  way  of  the  liga- 
tures or  from  the  extension  of  sloughing  to  parts  not 
previously  implicated.  The  danger  of  this  is  greatest 
during  the  first  twenty-four  hours,  but  is  by  no  means 
over  until  the  wound  is  well  healed. 

The  amount  of  bleeding  from  a  wound  depends  not 
only  upon  the  kind  and  size  of  the  cut  vessels,  but  upon 
the  manner  in  which  they  are  divided.  A  wound  cross- 
ing an  artery  will  occasion  more  severe  haemorrhage 
than  a  longitudinal  one,  an  incised  wound  more  than 
one  contused  or  lacerated,  and  a  mere  puncture  more 
than  a  completely  severed  artery. 

The  arteries  are  always  in  a  state  of  tension,  and, 
when  cut,  the  edges  retract  from  each  other  and  con- 
tract upon  themselves,  so  lessening  their  caliber.  The 
outlets  are  choked  by  the  coagulating  blood,  and,  when 
there  is  much  loss  of  blood,  fainting  ensues,  the  action 
of  the  heart  becomes  slower,  and  less  blood  is  sent  to 
the  wounded  part.  In  these  three  ways  Nature  tries  to 


GENERAL  PLAN  OF  THE  CIRCULATION 


CHART  OF  MAIN  ARTEKIES 


339 


340  A  TEXT-BOOK  OP  NURSING 

arrest  haemorrhage,  and  moderate  bleeding  will  soon  be 
checked  spontaneously  when  the  blood  is  in  a  normal 
condition. 

The  application  of  heat  or  cold  favors  the  formation 
of  clots  and  the  arterial  contraction;  elevation  of  the 
injured  part  reduces  the  force  with  which  the  blood  is 
sent  to  it;  these  will  often  be  the  only  treatment  re- 
quired, but  in  more  severe  cases,  when  blood  is  spurting 
from  a  wounded  artery,  further  measures  become  neces- 
sary. 

The  most  important  of  these,  and  one  usually  call- 
ing for  no  further  apparatus  than  one's  own  fingers,  is 
pressure  upon  the  bleeding  point  or  the  vessels  which 
supply  it.  There  is  no  danger  of  serious  haemorrhage 
from  a  wound  to  which  forcible  digital  pressure  can  be 
applied.  If  the  bleeding  vessel  is  too  deep  to  be  reached 
by  the  finger,  the  wound  can  be  plugged  by  a  compress 
of  lint.  To  make  this  most  effectively,  cut  a  number 


Direct  compression  of  a  wound  by  means  of  what  surgeons  call  a  graduated 
compress,  made  of  pads  of  lint,  folded  in  different  sizes,  with  the  largest 
one  on  top. 

of  small  bits,  each  a  little  larger  than  the  preceding, 
and,  beginning  with  the  smallest,  press  them  well  into 
the  wound.  The  pile  should  extend  to  some  little  height 
above  the  surrounding  level,  and  be  secured  by  a  tight 
bandage.  Such  compression  can  only  be  made  success- 
fully over  a  bony  surface;  where  the  artery  is  imbedded 
in  muscle,  it  becomes  difficult  if  not  impossible  to  con- 
trol it.  Wounds  of  the  head  and  face,  though  they  are 


COURSE  OF  THE  ARTERIES  341 

apt  to  bleed  profusely,  can  almost  always  be  controlled 
by  direct  pressure,  as  the  skull  affords  firm  counter- 
pressure.  If  the  bleeding  artery  can  not  be  reached  in 
this  way,  it,  or  the  branches  leading  to  it,  must  be  com- 
pressed at  some  point  nearer  the  source  of  supply. 
Thus,  bleeding  from  a  finger  or  toe  can  be  stopped  by 
making  pressure  on  both  sides  of  it,  above  the  wounded 
point.  So,  in  any  case,  firm  compression  of  the  bleed- 
ing vessel  between  the  wound  and  the  heart  will  ar- 
rest the  flow  of  blood.  In  order  to  be  able  proper- 
ly and  promptly  to  apply  such  pressure  in  time  of  need, 
every  nurse  should  familiarize  herself  practically  with 
the  course  of  the  main  arteries,  know  where  to  find 
them  and  how  to  control  them.  Actual  experiment 
is  the  only  way  of  rendering  the  knowledge  of  much 
utility. 

The  aorta,  the  main  trunk  of  the  arteries,  ascends 
from  the  upper  part  of  the  left  ventricle  for  a  short 
distance,  then  forms  an  arch  backward  over  the  root 
of  the  left  lung,  and  descending  upon  the  left  side  of 
the  spinal  column  passes  through  the  diaphragm  into 
the  abdomen.  It  is  known  in  its  different  parts  as  the 
ascending  and  descending  arch,  the  thoracic  and  ab- 
dominal aorta.  From  the  arch  of  the  aorta  arise  five 
branches:  the  arteria  innominata,  the  right  and  left 
coronary  arteries,  the  left  common  carotid,  and  the  left 
subclavian.  Of  these  the  innominata  is  the  largest.  It 
extends  for  only  about  two  inches,  and  then  divides  into 
the  right  common  carotid  and  right  subclavian.  The 
common  carotids  run  up  each  side  of  the  neck,  and 
divide  into  the  external  and  internal  carotids,  the  one 
with  its  branches  supplying  with  blood  the  face  and 
outside  of  the  skull,  and  the  other  penetrating  to  the 
brain,  through  an  opening  in  the  temporal  bone.  The 
23 


342  A  TEXT-BOOK  OF  NURSING 

coronary  arteries  return  and  supply  the  walls  of  the 
heart. 

Each  of  the  subclavians  runs  along  a  groove  in  the 
first  rib,  and  it  is  against  this  that  pressure  is  made  to 
control  the  circulation  in  the  shoulder  and  arm.  It 
turns  downward  over  this  rib,  and  takes  the  name  of 
axillary  fgr  a  short  distance  and  then  brachial.  The 
brachial  proceeds  down  the  arm  along  the  inner  border 
of  the  biceps  muscle  to  the  front  of  the  elbow,  just 
below  which  it  divides  into  the  radial  and  ulnar  arteries, 
which  continue  down  the  arm,  one  on  each  side,  to  the 
hand.  In  the  hand,  they  and  their  branches  reunite 
into  a  semicircle  called  the  palmar  arch.  From  this 
small  arteries  are  sent  off  to  each  of  the  fingers.  All 
these  can  be  traced  back  to  their  origin  at  the  arch  of 
the  aorta. 

The  aorta  reaches  as  high  as  the  third  dorsal  verte- 
bra, then,  descending,  passes  through  the  diaphragm  at 
about  the  level  of  the  twelfth  dorsal.  Opposite  the 
fourth  lumbar  vertebra  it  divides  into  the  right  and  left 
primitive  or  common  iliac  arteries..  These  are  about 
two  inches  long.  They  diverge  outward  and  downward, 
and,  opposite  the  fifth  lumbar  vertebra  and  the  sacrum, 
divide  into  the  external  and  internal  iliacs.  The  in- 
ternal iliacs,  after  a  course  of  about  an  inch  and  a  half, 
are  split  up  into  numerous  branches  supplying  the  pel- 
vic viscera. 

Each  external  iliac  continues  downward  and  out- 
ward along  the  brim  of  the  pelvis,  and,  half-way  be- 
tween the  anterior  spine  of  the  ileum  and  the  symphy- 
sis  pubis,  runs  under  Poupart's  ligament,  and  takes  the 
name  of  femoral.  The  pulsations  in  this  can  be  dis- 
tinctly felt  at  the  groin.  It  descends  along  the  inner 
side  of  the  thigh  in  a  nearly  straight  line  till  it  reaches 


HEMORRHAGES  343 

the  lower  third,  where  it  again  changes  its  direction 
and  its  name,  becoming  the  popliteal,  and  passing  to 
the  back  of  the  thigh  and  down  behind  the  knee.  Here 
it  divides  into  the  anterior  and  posterior  tibials,  which 
run  down  either  side  of  the  leg,  and  finally  anastomose 
into  the  plantar  arch,  as  do  the  ulnar  and  radial  arteries 
into  the  palmar.  From  the  plantar  arch  branches  go 
to  the  toes. 

The  other  principal  branches  of  the  descending 
aorta  are  the  intercostals,  the  phrenic  artery,  the  cceliac 
axis,  and  the  superior  and  inferior  mesenteries.  These 
supply  various  internal  organs. 

The  arteries  most  commonly  compressed  for  the  re- 
lief of  haBmorrhage  are  the  subclavian,  the  brachial, 


Manner  of  compressing  an  artery  with  a  handkerchief  and  stick. 

and  the  femoral.  You  should  at  least  know  how  to  find 
and  manage  these.  If  pressure  can  not  be  made  forcibly 
enough  by  the  fingers,  or  if  it  needs  to  be  maintained 
for  any  length  of  time,  a  tourniquet  can  be  used  upon 
the  brachial  or  femoral  arteries.  Before  applying  it, 
elevate  the  limb  as  high  as  possible,  make  a  few  turns 
of  bandage  about  it  to  protect  the  skin,  and  place  a 
hard  pad  directly  over  the  course  of  the  artery.  In  the 
absence  of  the  regular  apparatus,  an  impromptu  tourni- 


344  A  TEXT-BOOK  OF  NURSING 

quet  may  be  made  of  a  handkerchief  or  strip  of  muslin, 
with  a  hard  knot  or  a  smooth  stone  tied  in  the  middle. 
Fasten  this  rather  loosely  around  the  limb  and  twist  it 
with  a  stick  on  the  opposite  side,  keeping  the  knot  over 
the  injured  artery  until  pressure  enough  is  made  to 
completely  occlude  it.  This  is  sometimes  called  a  field 
tourniquet.  It  will  be  of  no  use  whatever  unless  so 
fixed  as  to  make  pressure  directly  upon  the  main  trunk 
of  the  artery.  A  tourniquet  may  remain  on  the  arm 
for  an  hour,  on  the  thigh  for  two  hours — not  more,  as 
the  part  will  die  if  its  nutrition  is  cut  off  too  long. 

The  subclavian  artery  can  not  be  reached  by  a  tour- 
niquet. The  handle  of  a  large  key,  or  a  blunt  stick, 
suitably  covered,  may  be  pressed  forcibly  against  it, 
behind  the  clavicle  at  the  outer  third  of  the  first  rib,  in 
case  of  severe  haemorrhage  from  the  shoulder  or  axilla. 

Esmarch's  plan  for  preventing  haemorrhage  during 
an  operation  upon  a  limb  is  to  apply  a  very  tight  rubber 
bandage  spirally  from  its  extremity  to  a  point  above 
the  site  of  the  proposed  incision.  Where  this  stops,  a 
piece  of  rubber  tubing,  with  hooks  at  the  end,  is  wound 
several  times  tightly  around  the  limb  and  fastened. 
The  bandage  is  then  removed,  when  the  circulation  will 
be  found  to  be  almost  completely  cut  off.  Where  there 
is  danger  of  secondary  haemorrhage  from  a  limb,  it  is 
well  to  keep  at  hand  a  piece  of  heavy  rubber  tubing, 
which  can  be  used  as  a  tourniquet  in  case  of  need.  A 
piece  of  tubing  cut  from  a  syringe  will  answer. 

With  any  secondary  haemorrhage  the  first  thing  to 
be  done  is  to  remove  all  dressings  so  as  to  expose  the 
wound  to  the  air.  Make  digital  pressure  upon  the 
wound,  if  it  can  be  reached,  assisted  by  pressure  on  the 
main  artery,  and  notify  the  surgeon  at  once. 

Flexion  of  a  limb  will  sometimes  aid  in  arresting 


HEMORRHAGES  345 

haemorrhage.  Put  in  the  joint  a  firm  roll  of  lint, 
against  which  the  pressure  will  come  when  the  limb 
is  bent.  In  case  of  bleeding  from  tb.e  palm  of  the  hand, 
which  will  sometimes  be  profuse,  direct  the  patient  to 
clasp  closely  a  wad  of  lint,  at  the  same  time  holding 
the  hand  high  above  the  head. 

Besides  those  named — heat  or  cold,  position,  and 
pressure — there  is  still  another  means  of  arresting 
hemorrhage  to  which  a  nurse  may  in  an  extremity  re- 
sort, namely,  use  of  astringents.  Astringents  used  ex- 
ternally are  called  styptics.  The  most  useful  are  the 
subsulphate  or  the  perchloride  of  iron,  alum,  gallic  acid, 
and  matico.  Wring  out  a  piece  of  lint  in  the  dilute  solu- 
tion, and,  having  first  wiped  out  the  blood-clots,  stuff  it 
into  the  wound.  The  mode  of  action  is  by  increasing 
the  contractile  power  of  the  vessels.  Nitrate  of  silver 
or  lunar  caustic  acts  somewhat  similarly.  Obstinate 
bleeding  from  a  small  point,  as  a  leech-bite,  may  be 
checked  by  touching  with  this.  Lunar  caustic  is  some- 
times spoken  of  as  the  potential  cautery,  having  the 
effect,  though  more  superficially,  of  cauterization. 

The  actual  cautery — the  application  to  the  wound  of 
a  hot  iron — is  sometimes  employed  by  surgeons  when 
the  bleeding  is  from  many  vessels  over  a  large  surface, 
or  from  a  porous  part  which  will  not  hold  a  ligature. 
Both  styptics  and  the  cautery  prevent  primary  union, 
and  are  only  employed  when  no  other  means  will  an- 
swer. General  oozing  from  a  large  surface  or  cavity  can 
nearly  always  be  checked  by  packing  it  with  iodoform 
gauze. 

The  method  most  commonly  used  by  surgeons  for 
the  arrest  of  haemorrhage  from  an  artery  of  any  size  is 
ligation.  The  artery  is  picked  up  by  a  pair  of  forceps, 
and  a  ligature  tied  firmly  about  it.  A  ligature  should 


346 


A  TEXT-BOOK  OF  NURSING 


be  about  eighteen  inches  long.  It  was  formerly  made  of 
strong,  soft  silk,  but  catgut  is  now  employed  in  wounds 
which  are  to  be  completely  closed,  since  the  latter  is 
absorbed  and  does  not  require  to  be  removed.  Test  its 
strength  well,  so  as  to  leave  no  chance  of  its  breaking 
when  strained;  and,  if  you  have  it  to  tie,  be  sure  and 
make  a  firm  knot.  Surgeons  use  generally  the  "  reef 
knot,"  a  square  knot  in  which  both  ends  of  one  string 


pass  either  over  or  under  the  loop  made  by  the  other; 
if  the  ends  are  separated  by  the  loop,  you  get  a  "  gran- 
ny "  knot,  which  will  slip.  The  string  in  the  right  hand 
should  be  held  over  the  other  in  the  first  twist,  and  un- 
der it  in  the  second,  or  vice  versa.  This  knot  may  be 
made  additionally  secure,  by  making  the  second  turn 
twice  instead  of  once  before  drawing  it  tight — the  so- 
called  "  surgeon's  knot."  You  should  practice  these 
knots,  and  also  the  "  clove  hitch,"  which  is  often  called 
for.  For  this,  make  two  loops  in  the  cord  from  right  to 
left,  and  put  the  first  over  the  second.  Loops  in  oppo- 
site directions  will  make,  if  they  hitch  at  all,  the  much 
less  reliable  "  cat's  paw." 


HAEMORRHAGES  34:7 

Another  mode  of  arresting  haemorrhage,  frequently 
employed,  is  that  of  torsion,  the  artery  being  seized  in 
the  forceps  and  twisted,  rendering  a  ligature  unneces- 
sary. Still  another  way,  though  now  rarely  adopted,  is 
by  acupressure.  A  harelip  pin  is  placed  about  the  open 
mouth  of  the  vessel,  and  a  wire  twisted  over  it  in  the 
shape  of  a  figure  8. 

The  most  dangerous  form  of  venous  haemorrhage  is 
that  from  rupture  of  large  varicose  veins.  Pressure 
should  be  made  ~bdow  the  bleeding  point,  cold  or  heat 
applied,  and  the  limb  elevated.  Pressure  above  the 
point  of  injury  is  here  useless  and  absurd.  Ligation  is 
avoided,  as  it  is  likely  to  occasion  inflammation  of  the 
vein.  In  cases  where  there  is  danger  of  such  rupture, 
an  elastic  stocking  or  bandage  should  be  worn,  to  sup- 
port and  make  equable  pressure  upon  the  distended 
vessel.  This  should  be  put  on  before  getting  up  in  the 
morning. 

Capillary  haemorrhage  is  never  dangerous,  and  can 
easily  be  checked  by  cold  and  position,  or  by  hot  water, 
an  especially  valuable  haemostatic  in  such  cases.  It 
must  be  used  as  hot  as  it  can  be  borne.  Warm  water 
will  only  increase  the  flow  of  blood. 

There  are  some  persons  who  have  what  is  called  the 
hgemorrhagic  diathesis — that  is,  an  excessive  tendency 
to  bleed — so  that  even  a  slight  cut  or  scratch  may  be 
followed  by  haemorrhage  difficult  to  control.  This  is 
more  common  in  male  subjects,  especially  children.  If 
such  a  case  comes  into  your  hands,  you  will  probably 
have  to  resort  to  styptics.  To  stop  the  bleeding  after 
a  tooth  has  been  extracted,  a  good  application  is  a  little 
piece  of  burnt  alum  pressed  well  into  the  cavity  and 
packed  down  with  lint. 

The  constitutional  symptoms  of  extreme  haemor- 


348  A  TEXT-BOOK  OF  NURSING 

rhage  are  those  of  shock,  pallor,  coldness  of  the  ex- 
tremities, clammy  sweat,  feeble  or  sighing  respiration, 
small  and  rapid  pulse,  restlessness  and  thirst,  vertigo, 
dimness  of  vision,  ringing  in  the  ears,  difficulty  in  ar- 
ticulation, followed,  if  the  trouble  is  not  before  this 
brought  to  an  end,  by  unconsciousness,  slight  convulsive 
movements,  and  death.  The  haemorrhage  usually 
ceases,  or  is  much  lessened,  with  syncope.  The  same 
effects  follow  internal  haemorrhage,  and  may  be  the  only 
evidence  of  its  existence,  though  usually  the  blood  will 
somewhere  find  an  outlet,  unless  the  bleeding  is  intra- 
peritoneal.  Convulsions  may  be  the  first  conspicuous 
indication.  A  dangerous,  often  fatal,  form  of  internal 
haemorrhage  results  from  the  rupture  of  an  extra-ute- 
rine pregnancy.  Suspicion  should  be  aroused  if  the 
patient  has  missed  a  menstrual  period  and  complains 
of  a  sudden  agonizing  pain  in  the  abdomen. 

If  blood  comes  from  the  lungs — hcemoptysis — it  is 
usually  coughed  up,  is  bright  red,  and  more  or  less 
frothy  from  the  admixture  of  air.  It  is  always  a  serious 
symptom,  though  the  quantity  of  blood  lost  is  rarely 
great;  but  blood  supposed  to  be  from  the  lungs  is  not 
infrequently  from  the  mouth  or  throat. 

The  vomiting  of  blood,  hcematemesis,  is  usually  some- 
what less  ominous.  The  patient  is  likely  to  have  a  sense 
of  fullness  and  oppression  in  the  epigastric  region,  and 
then  to  throw  up,  without  much  nausea,  a  large  quan- 
tity of  dark  blood,  mixed  with  food,  but  containing  no 
air,  acid  in  reaction,  and  incoagulable. 

In  either  case,  keep  the  patient  quiet  and  cool,  the 
head  elevated.  Give  bits  of  ice,  having  them  swallowed 
whole  if  possible;  and  if  the  haemorrhage  is  repeated, 
apply  ice-cold  cloths  externally.  Give  only  fluid  food, 
cold,  and  in  small  quantities. 


HAEMORRHAGES  349 

In  cases  of  internal  haemorrhage,  particularly  from 
the  lungs,  much  may  he  done  to  arrest  it  by  partially 
cutting  off  the  venous  return  from  the  limbs,  by  means 
of  straps  or  bandages  applied  tightly  around  their  proxi- 
mal extremities.  This  procedure,  by  diminishing  tem- 
porarily the  amount  of  blood  in  the  circulation,  will  di- 
minish its  force,  and  give  an  opportunity  for  coagula  to 
form  in  the  bleeding  vessels.  Ordinary  shawl-straps 
will  answer  the  purpose  well.  They  should  be  applied 
to  one  arm  and  the  opposite  thigh,  left  in  position  for 
not  more  than  five  minutes,  then  removed,  and  the 
other  arm  and  thigh  similarly  treated.  This  may  be 
continued  until  the  haemorrhage  ceases,  alternating  the 
sides,  and  taking  off  one  pair  of  straps  before  putting 
on  the  others. 

When  an  exhausting  haemorrhage  has  occurred,  after 
its  source  has  been  controlled,  the  limbs  may  be  tightly 
bandaged  from  their  distal  extremities  to  the  trunk,  in 
order  to  prevent  the  circulation  in  them  of  blood  which 
is  needed  by  the  vital  organs.  The  object  in  both  the 
above  procedures  is  to  gain  time.  The  same  care  must 
be  taken  not  to  leave  the  bandages  on  too  long. 

With  haematemesis  some  blood  will  almost  invaria- 
bly appear  in  the  next  stool  as  a  dark,  tarry  substance. 
For  haemorrhage  from  the  bowels,  ice-cold  injections 
may  be  given,  and  in  the  same  way  solutions  of  vege- 
table astringents — as  oak  bark,  tannic  acid,  catechu, 
etc.  Make  cold  applications  over  the  abdomen.  It 
may  be  well  to  give  a  small  dose  of  opium  to  diminish 
the  peristaltic  action.  This  may  occur  in  the  course 
of  typhoid  or  yellow  fever,  but  is  more  common  from 
haemorrhoids  than  from  any  other  cause. 

With  hatmaturia,  keep  the  patient  lying  down,  and 
give  hot  or  ice-cold  injections  into  the  rectum  or  va- 


350  A  TEXT-BOOK  OF  NURSING 

gina.  Blood  in  the  urine  may  come  either  from  the 
kidneys,  bladder,  or  urethra.  Note  whether  it  appears 
at  the  beginning  or  end  of  micturition,  and  whether  its 
passage  is  accompanied  by  pain.  Blood  from  the  kid- 
neys is  dark  and  clotted;  from  the  bladder  it  is  clear, 
as  a  rule. 

In  case  of  uterine  haemorrhage,  especially  when  fol- 
lowing operations,  a  vaginal  douche  of  hot  water,  or  a 
hot  solution  of  alum,  is  especially  indicated.  The  fluid 
extract  of  ergot,  or  gallic  acid,  may  be  given  internally. 
It  may  be  necessary  to  plug  the  vagina.  One  way  of 
doing  this  is  to  introduce  as  far  as  the  mouth  of  the 
uterus  the  center  of  a  soft  handkerchief,  leaving  the 
ends  projecting.  Pack  this  with  small  pieces  of  com- 
pressed sponge,  gauze,  or  cotton,  and  tie  the  projecting 
ends  together.  Cotton  is  best,  but  not  absorbent  cotton. 
After  a  sufficient  time  the  plugs  can  be  removed,  one 
at  a  time,  and,  finally,  the  handkerchief.  Another  way 
is  by  means  of  a  kite-tail  tampon — a  series  of  bunches 
of  cotton  tied  at  intervals  of  a  couple  of  inches  along 
one  string.  These  are  introduced,  one  at  a  time,  till  the 
vagina  is  distended,  and  the  end  of  the  string  left  hang- 
ing. Upon  pulling  this,  the  plugs  easily  come  out  in 
succession.  Ordinary  lamp-wicking,  sterilized,  makes  a 
good  tampon.  Haemorrhage  following  childbirth  is 
called  post-partum.  Special  directions  for  its  treatment 
are  given  in  the  chapter  on  obstetrics. 

There  is  one  other  local  hemorrhage  which  demands 
some  special  attention — epistaxis,  bleeding  from  the 
nose.  This  may  be  either  the  result  of  an  accident  or 
a  spontaneous  outbreak.  In  the  latter  case  it  may  be 
looked  upon  as  an  effort  of  nature  to  relieve  the  head, 
and  need  seldom  be  regarded  with  any  uneasiness.  To 
check  it,  make  pressure  on  the  facial  artery  at  the  root 


EMERGENCIES,   SURGICAL  AND  MEDICAL     351 

of  the  nose,  with  cold  applications  to  the  forehead  and 
back  of  the  neck.  The  ordinary  position  taken — lean- 
ing over  a  basin — is  the  worst  possible.  Make  the  pa- 
tient stand  erect,  throw  his  head  back  and  elevate  his 
arms,  while  you  hold  a  cold,  damp  sponge  to  the  nos- 
trils. If  the  bleeding  still  persists  beyond  a  reasonable 
time,  the  nostrils  should  be  syringed  with  salt  and 
water,  ice  cold  (3  j-0  j),  or  a  solution  of  alum  or  iron. 
There  are  very  few  cases  that  these  measures  will  not 
control.  Avoid  blowing  the  nose,  and  so  disturbing  the 
formation  of  clots.  If  all  other  means  fail,  the  surgeon 
may  find  it  necessary  to  plug  the  nares.  To  do  this,  he 
will  need  a  small  flexible  catheter,  a  strong  cord,  and 
some  lint.  The  cord  is  passed  through  the  eye  of  the 
catheter  and  carried  by  it  through  the  nostril  to  the 
pharynx,  where  the  end  of  the  string  can  be  caught  and 
brought  out  through  the  mouth.  By  means  of  this  a 
plug  of  lint  is  drawn  into  the  posterior  naris;  another 
is  pushed  into  the  anterior,  and  the  two  tied  together 
so  as  to  hold  each  other  in  place.  They  should  be  left 
in  for  twenty-four  hours.  The  process  is  a  very  pain- 
ful one,  and  is  only  resorted  to  when  all  other  means 
prove  ineffectual. 

Broken  bones  are  among  the  most  common  casual- 
ties. It  is  a  mistaken  impression  that  a  fracture  must 
be  set  immediately.  It  will  do  less  harm  for  it  to  be 
left  a  day  or  two  without  splints  than  for  them  to  be 
awkwardly  applied.  Handle  the  injured  part  as  little 
as  possible,  and  do  not  attempt  to  do  more  than  to  keep 
the  patient  comfortable  and  quiet  until  a  competent 
surgeon  can  be  obtained.  Temporary  splints  may  be 
put  on,  made  of  pasteboard,  shingles,  or  any  smooth  and 
stiff  material  at  hand,  to  prevent  the  spasmodic  twitch- 
ing of  the  muscles,  which  adds  to  the  pain.  If  it  is  a 


352  A  TEXT-BOOK  OF  NURSING 

limb  that  is  broken,  place  it  in  a  natural  position,  mak- 
ing some  extension,  and  support  it  firmly,  elevating  the 
limb  slightly.  A  broken  leg  may  be  laid  on  a  pillow, 
which  is  then  bandaged  closely  around  it,  or  it  may  be 
bound  to  a  straight  padded  stick,  or  even  to  the  other 
leg.  In  fracture  of  the  patella,  the  foot  should  be  ele- 
vated to  a  considerable  height,  and  the  leg  kept  straight 
by  a  long  splint  at  the  back.  Put  a  pad  under  the  knee. 
For  a  fractured  thigh,  extend  the  limb  and  bind  it 
against  a  splint  long  enough  to  reach  from  the  axilla 
to  the  heel.  With  a  broken  arm,  bend  the  elbow,  keep- 
ing the  thumb  up,  fasten  a  well-padded  splint  on  each 
side,  and  place  the  arm  in  a  sling.  With  a  fractured 
clavicle,  lay  the  patient  on  his  back,  without  a  pillow, 
with  the  arm  of  the  injured  side  bound  across  the  chest. 
For  fractured  ribs,  keep  the  patient  quiet  in  bed;  put 
a  broad  bandage  tightly  around  the  chest  to  limit  its 
movements;  note  whether  any  blood  is  raised.  If  skull 
fracture  is  suspected,  keep  the  patient  in  a  quiet,  dark 
room,  on  his  back,  with  the  head  slightly  raised;  apply 
cold  cloths  to  the  head.  If  blood  or  serum  is  oozing 
from  the  ears,  do  not  let  it  putrefy,  or  it  may  set  up  an 
inflammation  in  the  brain.  Wash  the  external  ear,  and 
put  in  a  little  antiseptic  pad.  For  fracture  of  the  jaw, 
close  the  mouth,  and  fix  in  place  with  a  bandage. 

When  a  dislocation  occurs,  it  is  much  more  impor- 
tant for  it  to  be  speedily  reduced,  as  the  muscular  ten- 
sion increases  and  the  reduction  becomes  more  difficult 
with  each  hour  that  passes.  There  are  one  or  two  which 
you  may  try  yourself  to  put  in  place.  Dislocation  of 
the  jaw  is  one  easily  managed,  and  in  which  delay  is 
particularly  trying  to  the  patient,  as  it  will  be  fixed 
immovably,  rendering  him  unable  to  speak.  To  reduce 
this,  place  the  thumbs  on  the  back  teeth  and  the  fingers 


EMERGENCIES,  SURGICAL  AND  MEDICAL     353 

under  the  jaw.  Depress  forcibly  the  angle  of  the  jaw, 
at  the  same  time  lifting  the  chin.  The  thumbs  need 
to  be  well  protected,  for  the  jaw  will  slip  in  place  with 
a  snap,  and  unless  they  are  quickly  moved  aside  they 
may  get  badly  bitten.  Dislocations  of  the  fingers  can 
generally  be  reduced  by  forcibly  pulling  them.  A 
thumb  out  of  place  is  more  difficult,  sometimes  impos- 
sible to  return.  Too  much  force  should  not  be  used  in 
the  attempt.  Larger  joints  you  will  hardly  dare  to 
meddle  with,  owing  to  the  difficulty  of  making  a  posi- 
tive diagnosis  and  the  danger  of  creating  complications. 
After  any  dislocation  the  joint  will  for  some  time  be 
weak,  and  liable  to  a  recurrence  of  the  accident,  so  that, 
when  it  has  once  been  reduced,  the  parts  should  be 
firmly  bandaged  or  strapped  in  place,  until  they  have 
grown  quite  strong  again. 

Sprains  occur  most  frequently  at  the  wrist  and 
ankle-joint.  They  should  not  be  made  light  of,  for,  if. 
neglected,  their  results  may  be  permanent.  Put  the 
joint  in  such  position  that  it  will  have  complete  rest. 
Soak  in  water  as  hot  as  can  be  borne,  gradually  increas- 
ing the  temperature,  for  half  an  hour,  then  apply  hot 
cloths  for  another  half  hour,  and  finally  a  moist  band- 
age, keeping  the  part  elevated.  Massage  is  useful  later, 
and  when  the  swelling  goes  down  the  joint  should 
be  supported  by  rubber  bandages,  adhesive  straps,  or 
a  plaster-of-Paris  splint. 

Contusions,  or  bruises,  are  best  treated  by  rest  and 
hot  applications.  After  a  general  contusion  a  warm 
bath  may  be  found  helpful.  Severe  contusion  is  often 
followed  by  symptoms  of  shock.  A  painfully  crushed 
finger  or  toe  may  be  wrapped  in  soft  cloths  wet  with 
hot  water  and  a  little  laudanum.  Do  not  use  arnica  or 
any  of  the  strong  patent  liniments.  Listerine  is  excel- 


354  A  TEXT-BOOK  OF  NURSING 

lent,  and  a  mixture  of  alcohol  and  water  or  salt  and 
water,  will  be  found  stimulating. 

With  contused  and  lacerated  wounds  there  must  be 
especial  care  in  cleaning  out  the  blood-clots.  In  the 
case  of  all  wounds  there  are  five  points  to  be  attended 
to:  To  arrest  the  haemorrhage,  to  cleanse  the  wound, 
to  bring  the  cut  surfaces  together,  to  see  that  there  is  a 
way  of  escape  for  any  discharge,  and  to  protect  the 
wound  from  the  air.  With  all  extensive  wounds,  espe- 
cially those  of  the  thoracic  and  abdominal  cavities,  rest 
is  important.  When  the  chest  is  injured,  lay  the  pa- 
tient on  the  wounded  side  rather  than  the  other. 

A  ghastly  effect  is  often  produced  by  a  wound  which 
bleeds  freely,  but  which,  when  it  is  cleansed,  proves  un- 
important. This  is  apt  to  be  the  case  with  cuts  about 
the  head  and  face.  In  washing,  do  not  touch  the  wound 
itself,  but  irrigate  or  squeeze  a  stream  of  antiseptic 
solution  over  it.  When  you  are  sure  that  no  dirt  or 
other  foreign  matter  is  left  in  it,  bring  the  edges  as 
nearly  as  you  can  to  their  original  position;  if  the 
wound  is  but  slight,  they  may  be  held  in  place  by  ad- 
hesive strips,  leaving  room  between  them  for  the  es- 
cape of  blood  and  pus.  Over  this  put  some  simple  dress- 
ing, to  exclude  the  air.  On  the  scalp,  the  hair  must  be 
cut  or  shaved  off  about  the  wound  before  the  strips  are 
applied.  For  a  deep  incision,  or  one  that  can  not  be 
held  together  by  adhesive  plaster  surgeons  use  sutures 
of  silk,  catgut,  or  fine  wire.  To  introduce  these,  a 
needle  with  a  cutting  edge  is  required.  A  cut  finger 
needs  only  to  have  the  edges  brought  snugly  together 
and  bandaged.  For  slight  wounds,  collodion  is  some- 
times used  in  place  of  plaster  after  the  bleeding  is 
checked.  This  is  a  solution  of  gun-cotton  in  ether. 
When  applied,  the  ether  evaporates,  leaving  an  adhe- 


EMERGENCIES,   SURGICAL  AND  MEDICAL     355 

sive,  transparent,  and  highly  contractile  film.  One 
layer  only  is  to  be  used,  as  it  contracts  so  forcibly  that 
a  second  will  drag  off  the  first.  The  parts  must  be 
held  together  until  it  is  dry.  It  is  useless  to  apply  it 
over  a  wet  surface.  With  a  little  absorbent  cotton,  it 
makes  an  excellent  dressing,  more  durable  than  the  col- 
lodion alone.  If  a  finger,  a  portion  of  the  scalp,  or  any 
small  part  is  almost  entirely  cut  off,  there  is  still  a 
chance  of  its  growing  on  again,  if  it  is  cleaned,  imme- 
diately replaced  in  the  proper  position,  and  so  bound 
on  that  a  firm  and  even  pressure  is  made.  The  experi- 
ment is  at  least  worth  trying,  for  even  if  it  fails  there 
is  no  great  harm  done. 

With  a  punctured  wound,  the  important  point  is  to 
keep  it  open  until  it  heals  from  the  bottom.  If  made 
by  a  splinter  or  thorn,  this  must  be  entirely  removed, 
not  by  poking  at  it,  but  by  making  a  sharp  incision 
along  its  course,  so  that  you  can  get  at  and  withdraw 
it.  The  incision,  though  it  seems  like  increasing  the 
wound,  is  likely  to  heal  sooner  and.  better  than  the 
puncture.  If  the  splinter  goes  under  the  finger-nail, 
trim  or  split  the  nail  down  to  the  end  of  the  splinter. 

Never  try  to  extract  a  fish-hook  or  any  barbed  in- 
strument by  the  hole  at  which  it  entered.  Push  it  all 
the  way  through  and  break  off  the  head. 

In  case  of  the  bite  of  a  venomous  snake  or  other 
probably  poisoned  wound,  the  bleeding  should  be  en- 
couraged rather  than  checked.  Bathe  it  in  warm  water. 
Ligate  the  limb,  if  possible,  above  the  point  of  injury, 
and  suck  it,  being  careful  not  to  swallow  the  poison. 
If  the  heart's  action  seems  affected,  keep  the  patient 
lying  down,  and  give  stimulants  to  the  verge  of  intox- 
ication. Ammonia-water  may  be  used  both  externally 
and  internally.  Cauterize  the  wound  deeply,  and  then 


356  A  TEXT-BOOK  OF  NURSING 

poultice  it.  Prompt  excision  of  the  wounded  area  has 
been  recommended.  The  bite  of  any  animal  may  be 
regarded  with  suspicion.  That  of  the  cat  or  rat  is  said 
to  be  more  dangerous  than  that  of  the  dog.  Treat  the 
bites  and  stings  of  insects  with  ammonia  or  soda.  Take 
care  that  the  sting  of  a  wasp  or  bee  is  not  left  in  the 
wound,  as  it  may  set  up  serious  irritation.  A  good  way 
to  remove  it  is  to  make  strong  pressure  around  the  spot 
with  the  barrel  of  a  watch-key.  Listerine  or  peroxide 
of  hydrogen  will  relieve  the  pain. 

The  eruption  from  the  Rhus  toxicodendron  (poison 
ivy  or  mercury)  or  of  the  Rhus  venenata  (poison  oak, 
dogwood,  or  sumach)  is  commonly  treated  with  a  satu- 
rated solution  of  bicarbonate  of  soda  or  an  acetate  of 
lead  wash.  I  have  found  listerine  more  soothing,  and 
a  strong  hot  decoction  of  sweet  fern  leaves  is  also  good. 

Perhaps  the  most  alarming  accidents  are  those  re- 
sulting from  fire.  If  your  own  clothes  catch  fire,  lie 
down  on  the  floor  and  roll,  keeping  your  mouth  shut. 
If  you  see  another  woman  in  the  same  danger — it  is 
most  likely  to  be  a  woman — throw  her  down,  and  wrap 
around  her  a  shawl,  rug,  or  any  heavy  woolen  thing  at 
hand,  to  stifle  the  flames.  Begin  at  the  head,  and  keep 
the  fire  as  much  as  possible  from  the  face.  The  great 
danger  is  that  of  inhaling  the  flames. 

In  the  treatment  of  burns  or  scalds,  the  first  object 
is  to  exclude  the  air.  This  will  at  once  allay  the  pain. 
If  the  injury  is  superficial,  mere  reddening  of  the  sur- 
face, sprinkle  it  thickly  with  bicarbonate  of  soda  and  tie 
a  wet  bandage  over  it  till  the  pain  subsides.  Then  the 
part  may  be  protected  from  the  action  of  the  air  by 
painting  it  over  with  the  white  of  an  egg.  As  one  layer 
dries,  a  second  and  third  may  be  added.  Flexile  collo- 
dion, similarly  applied,  is  even  better,  but  it  is  not  one 


EMERGENCIES,   SURGICAL  AND  MEDICAL     357 

of  the  things  likely  to  be  at  hand  in  an  emergency. 
Another  plan  is  to  dust  with  flour  and  cover  with  a 
thick  layer  of  cotton  wool.  If  the  burn  is  severe  enough 
to  have  blistered  or  destroyed  the  cuticle,  the  latter 
remedy  should  not  be  employed,  for  the  discharge  will 
harden  the  flour  into  crusts,  and  the  fibers  of  the  cotton 
stick  to  the  wound,  and  can  not  be  detached  without 
pain.  Carron  oil — linseed  oil  and  limewater  in  equal 
parts — is  a  popular  remedy,  but  pure  olive  oil  or  vase- 
line is  as  good,  or  perhaps  better,  as  linseed  oil  often 
contains  irritating  impurities.  From  severe  burns  great 
deformity  sometimes  results,  through  the  contraction 
of  the  skin  in  healing.  It  may  be  quite  unavoidable, 
but  something  can  be  done  toward  preventing  it,  by 
keeping  the  burned  parts  in  the  best  position,  not  al- 
ways the  easiest.  A  severe  burn  is  usually  accompanied 
by  more  or  less  shock,  to  be  treated  according  to  the 
directions  already  given. 

The  burns  produced  by  strong  acids  are  treated  in 
the  same  way  as  those  by  fire,  further  caustic  action 
being  prevented  by  first  bathing  with  some  weak  alka- 
line solution,  as  of  soda  or  ammonia.  Common  earth, 
picked  up  almost  anywhere,  contains  alkali  enough  to 
be  useful. 

Lime  or  caustic  potash  may  make  a  severe  burn. 
The  treatment  is  still  the  same,  the  alkali  being  first 
neutralized  by  some  acid,  as  diluted  vinegar  or  lemon 
juice,  about  a  teaspoonful  to  a  cup  of  water. 

If  a  fragment  of  lime  gets  into  the  eye,  bathe  it  at 
once  with  such  a  solution,  without  wasting  time  in  try- 
ing to  pick  it  out.  Any  foreign  body  in  the  eye  will 
occasion  a  great  deal  of  pain.  The  irritation  gives  rise 
to  an  abundant  secretion  of  tears,  which  will  sometimes 

wash  out  the  cause  of  trouble.    Dust  or  small  cinders 
24 


358  A  TEXT-BOOK  OF  NURSING 

may  be  cleared  out  by  drawing  the  upper  lid  well  down 
over  the  lower,  and  at  the  same  time  blowing  the  nose 
forcibly.  If  a  particle  gets  caught  under  the  lower  lid, 
draw  it  down  by  the  lashes,  direct  the  patient  to  turn 
the  eyeball  toward  the  nose,  and  the  offending  body 
can  then  be  wiped  out  with  a  soft  handkerchief.  If  it 
is  under  the  upper  lid,  that  can  be  turned  up  over  a 
knitting-needle,  or  a  small  pencil,  and  treated  in  the 
same  way.  Drawing  the  upper  lid  over  the  under,  sev- 
eral times,  at  the  same  time  pushing  up  the  latter, 
may  brush  it  out.  Always  wipe  the  eye  toward  the 
nose,  as  the  natural  secretions  flow  in  that  direction. 
If  the  particle  is  embedded  in  the  surface  of  the  eye- 
ball, it  will  have  to  be  picked  out  by  a  sharp  instrument. 
It  takes  a  surgeon  to  do  this  safely.  The  eyes  may  be 
bathed  with  rose-water  or  a  saturated  solution  of  bora- 
cic  acid. 

Foreign  bodies  in  the  ear  are  often  very  trouble- 
some. If  an  insect  gets  in,  hold  a  bright  light  close  to 
the  ear,  and  it  may  be  attracted  outward.  Then  try 
syringing  it  with  warm  salt  water.  If  these  measures 
are  not  successful,  lay  the  sufferer  down  on  the  other 
side,  straighten  the  tube  of  the  ear  by  pulling  the  tip 
upward  and  slightly  backward,  and  fill  it  with  warm 
olive  oil  or  glycerin.  The  insect  will  be  drowned  in 
this  and  float  to  the  surface.  If  some  hard  substance 
is  in  the  ear,  hold  it  downward  and  syringe  gently  with 
warm  water,  taking  care  not  to  close  the  opening  with 
the  nozzle  of  the  syringe.  Do  not  try  this  if  the  object 
is  anything  that  will  swell  with  moisture,  as  a  bean 
or  a  pea,  as  it  will  then  only  make  a  bad  matter  worse. 
Neither  poke  at  it,  as  it  may  be  easily  driven  in  beyond 
reach.  Bend  the  head  over  to  the  affected  side,  and 
shake  it.  Jump  up  and  down,  and  it  may  be  jarred  out. 


EMERGENCIES,  SURGICAL  AND  MEDICAL     359 

Otherwise,  get  a  doctor  as  soon  as  possible,  as  perma- 
nent injury  to  the  ear  may  result  if  the  obstruction  is 
not  removed. 

When  a  foreign  body  is  in  the  nostril,  make  the  pa- 
tient take  a  full  breath,  then  close  the  mouth  and  the 
other  nostril  firmly,  when  the  air,  having  no  other  way 
of  escape,  may  expel  the  obstruction.  Try  at  the  same 
time  to  blow  the  nose.  Tickling  it  with  a  feather,  or 
giving  snuff  to  cause  sneezing  may  help.  If  this  fails, 
and  the  object  is  in  sight,  compress  the  nostrils  above 
to  prevent  its  being  pushed  farther  up,  and  hook  it  out 
with  a  hairpin  or  a  bent  wire. 

Anything  stuck  in  the  throat,  or  oesophagus,  may 
sometimes  be  hooked  out  in  the  same  way,  if  it  is  too 
far  down  to  be  reached  by  the  fingers.  A  pair  of  blunt 
scissors  may  be  used  in  the  place  of  forceps.  It  is  hard- 
ly safe  to  try,  as  is  often  advised,  to  push  the  object 
down,  unless  it  is  some  digestible  substance  which  may 
be  trusted  to  soften  under  the  action  of  the  secretions. 
If  a  piece  of  bread  can  be  swallowed,  it  may  carry  down 
with  it  the  obstruction.  Once  swallowed,  there  need  be 
no  further  apprehension  on  account  of  the  size  of  the 
body,  as  whatever  will  pass  through  the  gullet  will  get 
through  the  rest  of  the  alimentary  canal  without  diffi- 
culty. Do  not  give  purgative  medicine  in  such  case, 
but  food  a  little  more  solid  than  usual,  in  which  it  will 
be  imbedded  and  carried  along  without  irritating  the 
passages. 

A  foreign  body  in  the  windpipe  will  usually  be  ex- 
pelled by  the  coughing  which  its  presence  excites.  The 
trachea  is  very  sensitive,  and  the  entrance  even  of  a 
drop  of  water  excites  great  irritation.  A  blow  on  the 
back  will  be  of  use  if  the  person  is  choking.  A  child 
may  be  taken  up  by  the  feet  and  tfeld  head  down 


360  A  TEXT-BOOK  OP  NURSING 

while  a  succession  of  blows  are  administered  between 
the  shoulders.  This  will  seldom  fail  to  dislodge  the 
object  unless  it  has  been  sucked  deeply  into  the  air 
passages. 

If  the  trachea  is  so  obstructed,  from  any  cause,  that 
the  supply  of  air  is  cut  off  from  the  lungs,  and  the  blood 
fails  to  be  oxygenated,  asphyxia  results.  This  is  what 
occurs  in  drowning,  strangulation,  and  suffocation  by 
irrespirable  gases.  The  action  of  the  lungs  may  under 
such  circumstances  have  ceased  some  time  before  death 
ensues,  and,  even  when  animation  is  too  far  suspended 
for  the  movements  of  the  chest  to  be  of  themselves  re- 
newed, the  lungs  may  sometimes  be  forced  into  action 
by  artificial  respiration.  There  are  two  methods  com- 
monly employed;  the  most  practiced  is  that  known  as 
"  Sylvester's  ready  method."  The  first  thing  to  be  done 
is  to  pull  the  tongue  forward  and  keep  it  there,  so  that 
it  will  not  fall  back  and  obstruct  the  trachea;  an  elastic 
band  over  the  tongue  and  under  the  chin  is  advised  for 
this  purpose.  Loosen  all  the  clothing,  and  lay  the 
patient  on  his  back,  with  head  and  shoulders  slightly 
raised.  Then,  standing  behind  him,  grasp  the  arms 
just  above  the  elbows,  and  draw  them  slowly  away  from 
the  sides  of  the  body  in  an  upward  direction  till  they 
meet  over  his  head.  Hold  them  in  this  position  for 
about  two  seconds,  then  bring  them  back  slowly  till 
the  elbows  meet  over  the  chest,  making  firm  pressure. 
With  the  first  motion  the  ribs  are  raised  by  the  pectoral 
muscles,  and  a  vacuum  is  created  in  the  lungs,  into 
which  the  air  rushes.  As  the  arms  are  brought  back  to 
the  sides,  the  air  is  again  forced  out,  as  in  natural 
respiration.  The  two  movements  should  be  repeated 
slowly  and  steadily,  not  more  than  sixteen  times  in  a 
minute,  and  persisted  in  until  respiration  takes  place 


EMERGENCIES,  SURGICAL  AND  MEDICAL     361 

naturally,  or  until  all  hope  of  establishing  it  must  be 
given  up.  It  is  not  to  be  considered  hopeless  under  two 
hours. 

"  Marshall  Hall's  method  "  is  sometimes  used  as  a 
substitute  for  or  alternating  with  Sylvester's.  The 
body  is  laid  flat  on  the  face,  and  gentle  pressure  made 
on  the  back,  after  which  it  is  turned  over  on  the  side; 
then  again  on  the  face,  and  the  pressure  reapplied.  Ee- 
peat  these  motions  at  a  rate  of  sixteen  to  the  minute. 
The  principle  is  the  same,  whichever  method  is  adopted. 
It  is  well  to  practice  one  or  both  of  them,  that  the  mo- 
tions may  be  familiar  if  suddenly  called  for.  Cessa- 
tion of  breath  for  more  than  two  minutes  is  usually 
fatal. 

When  a  person  is  apparently  drowned,  before  begin- 
ning artificial  respiration,  turn  the  face  down  for  a  mo- 
ment, and  clean  out  with  the  finger  any  accumulation  of 
mucus  that  may  be  at  the  base  of  the  tongue.  Hold  the 
body  in  such  a  way  that  by  gently  moving  it  back  and 
forth,  any  water  that  may  be  in  the  lungs  will  run  out 
through  the  mouth.  The  mucus  must  be  removed  from 
the  throat  in  the  same  way  in  case  of  strangulation. 
Kemove  all  constriction  from  the  neck.  If  hanging, 
cut  the  body  down,  but  do  not  let  it  fall.  In  poisoning 
from  carbonic-acid  gas  (choke  damp)  or  carbonic  oxide 
(the  fumes  of  burning  charcoal),  loosen  the  clothing, 
and,  if  the  body  is  still  warm,  dash  cold  water  over  it 
forcibly  and  frequently.  If  it  is  chilled,  use  hot  appli- 
cations instead.  In  all  cases  apply  artificial  respira- 
tion, and  give  stimulants  and  nourishment  as  soon  as 
they  can  be  swallowed. 

Sunstroke  or  heat  prostration  is  in  most  cases  pre- 
ceded by  headache,  dizziness,  and  more  or  less  mental 
disturbance.  Direct  exposure  to  the  rays  of  the  sun  is 


362  A  TEXT-BOOK  OF  NURSING 

not  essential;  it  may  be  produced  by  intense  heat  of  any 
kind.  Fatigue  and  foul  air  aggravate  the  tendency. 
The  alcoholic  habit  renders  one  especially  liable  to  it. 
Persons  who  have  once  been  so  affected  are  liable  to  a 
recurrence  of  the  attack  upon  exposure  to  heat.  The 
preliminary  symptoms  either  become  intensified  until 
delirium  sets  in,  or  the  patient  falls  suddenly  uncon- 
scious, the  face  pale  or  dusky,  or  intensely  red,  the  skin 
very  hot,  the  breathing  evidently  difficult,  and  the  pulse 
weak  and  fluttering.  There  are  occasionally  convul- 
sions, but  more  often  no  movement  after  the  first  in- 
sensibility till  death.  The  danger  is  imminent,  the 
bodily  temperature  sometimes  rising  to  112°  or  114°. 
The  first  thing  to  be  done  is  to  reduce  this.  Remove 
the  patient  into  the  shade,  take  the  clothing  from  the 
head  and  chest,  and  throw  cold  water  over  the  body,  or 
put  it  in  a  cold  bath,  gradually  reducing  the  degree  of 
cold.  Have  all  the  fresh  air  possible,  and  as  soon  as  a 
decline  in  heat  is  evident,  artificial  respiration  may  be 
resorted  to,  if  necessary.  If,  after  consciousness  is  re- 
stored, the  temperature  again  rises,  the  cold  applica- 
tions must  be  repeated.  Do  not  give  alcoholic  stimu- 
lants without  medical  advice.  Aromatic  spirits  of 
ammonia  may  be  used  if  a  stimulant  seems  called  for. 
When  death  takes  place  from  a  stroke  of  lightning, 
it  is  the  result  of  shock  to  the  nervous  system.  This 
may  be  enough  to  produce  unconsciousness  without  be- 
ing fatal,  and,  even  when  life  is  apparently  extinct, 
efforts  at  resuscitation  should  be  made  and  kept  up 
for  not  less  than  an  hour,  the  important  point  being 
borne  in  mind  to  preserve  the  warmth  of  the  body  by 
all  methods,  such  as  by  applications  of  the  hot  water 
bottle  or  cloths,  hot  flannels  or  warm  salt-bags.  Em- 
ploy artificial  respiration,  and  treat  otherwise  as 


EMERGENCIES,  SURGICAL  AND  MEDICAL     363 

directed  for  shock.  The  principal  lesions  may  be  burns, 
which  need  the  same  attention  as  burns  from  any  other 
source. 

Any  one  suffering  from  the  effects  of  severe  cold 
must  be  kept  away  from  the  heat,  as  there  will  other- 
wise be  danger  of  sloughing  of  the  frost-bitten  parts. 
A  person  found  frozen  should  be  taken  to  a  cold  room, 
undressed,  and  rubbed  with  snow,  or  cloths  wrung  out 
in  ice-water.  The  friction  should  be  continued,  espe- 
cially about  the  extremities,  until  the  circulation  seems 
restored;  at  the  same  time  artificial  respiration  may  be 
resorted  to  if  the  natural  is  at  a  standstill.  Give 
brandy  and  beef-tea  as  soon  as  the  patient  is  able  to 
swallow.  Only  by  degrees  bring  him  into  warmer  air. 
The  same  plan  is  pursued  with  any  frost-bitten  part, 
the  aim  being  to  restore  vitality  without  inducing 
sloughing.  Parts  of  the  body  may  be  frozen  without 
the  sufferer's  knowledge,  as  numbness  and  insensibility 
precede  the  later  stages. 

With  a  tendency  to  chilblains,  cold  feet  should  not 
be  too  quickly  heated.  They  should  be  warmly  and  al- 
ways loosely  clad,  bathed  with  cold  water  and  ammonia, 
rather  than  hot  water  and  soap.  In  the  early  stages, 
painting  them  with  iodine  will  relieve  the  itching.  If 
neglected,  they  may  develop  painful  and  intractable 
ulcers. 

Hernia,  rupture  of  the  peritonaeum,  with  protrusion 
of  the  abdominal  contents,  takes  place  either  in  the 
groin,  the  lower  front  of  the  abdomen,  or  at  the  umbili- 
cus. The  tumor  most  often  contains  a  loop  of  small 
intestine.  The  symptoms  are  intense  pain,  obstinate 
constipation,  and  persistent,  sometimes  stercoraceous 
vomiting.  Put  an  ice-bag  over  the  swelling,  give  no 
food,  no  physic,  very  little  drink,  and  send  at  once  for 


364:  A  TEXT-BOOK  OF  NURSING 

a  surgeon,  as  prompt  operative  measures  may  be  neces- 
sary. 

Convulsions  in  the  adult  are  most  commonly  either 
from  epilepsy  or  hysteria.  An  epileptic  seizure  may  be 
distinguished  from  fainting — syncope — by  the  convul- 
sive movements,  which  are  absent  in  the  latter.  The 
patient  falls  with  sudden  loss  of  consciousness,  and 
often  with  a  peculiar  sharp  cry.  The  face  is  at  first 
pale,  but  may  afterward  become  flushed;  there  is  froth- 
ing at  the  mouth,  with  jerking  motions  of  the  whole 
body  or  parts  of  it.  This  stage  only  lasts  a  few  mo- 
ments, after  which  the  patient  may  recover  conscious- 
ness or  lapse  into  stupor.  The  only  treatment  is  to  keep 
the  patient  from  hurting  himself  during  the  convul- 
sions. Lay  him  on  the  back,  the  head  slightly  elevated; 
loosen  the  clothing,  and  allow  plenty  of  fresh  air.  In- 
sert a  folded  towel  between  the  teeth,  to  keep  him  from 
biting  his  tongue.  Give  no  fluid.  These  attacks  are  in 
some  subjects  preceded  by  warning  sensations  of  vary- 
ing character,  known  as  the  "aura."  When  the  aura 
begins  in  a  hand  or  foot,  tying  a  tight  ligature  around 
the  limb  above  may  sometimes  abort  the  attack.  Con- 
firmed epileptics  are  usually  in  an  impaired  mental  con- 
dition, and  occasionally  these  seizures  are  followed  by 
acute  mania. 

Hysterical  fits,  most  common  in  young  girls,  may  be 
much  the  same  in  appearance,  but  the  patient  is  not 
really  unconscious,  and  never  hurts  herself.  Any  effort 
to  open  the  eyelids  will  usually  be  resisted,  and  the  eye- 
ball will  be  found  sensitive,  as  it  is  not  in  epilepsy. 
There  is  so  little  treatment  needed  in  either  case  that  it 
is  of  little  account  whether  or  not  you  are  sure  which  it 
is.  Keep  the  patient  quiet,  and  free  from  sympathetic 
spectators.  The  mere  suggestion  of  some  disagreeable 


EMERGENCIES,   SURGICAL  AND  MEDICAL     365 

remedy  will  often  terminate  the  seizure.  It  may  be 
followed  by  the  involuntary  passage  of  a  large  amount 
of  pale  urine. 

In  apoplexy  there  are  rarely  convulsions.  There  is 
sudden  loss  of  consciousness,  without  heart  failure,  the 
face  is  flushed,  or,  more  rarely,  very  pale,  the  respira- 
tion stertorous,  the  pulse  slow  and  full,  the  temperature 
at  first  lowered,  the  pupils  fixed  and  one  or  both  di- 
lated, with  paralysis  of  one  side.  There  may  be  reten- 
tion or  involuntary  passage  of  urine.  The  patient 
should  be  moved  no  more  than  is  absolutely  necessary. 
Loosen  the  clothes,  elevate  the  head  and  chest,  apply 
cold  to  the  head  and  warmth  to  the  extremities.  Act 
on  the  bowels,  but  do  not  give  stimulants  or  emetics. 
Apoplexy  may  be  confounded  with  intoxication,  espe- 
cially when  the  patient  has  recently  been  taking  liquor 
and  carries  the  odor  of  it  in  his  breath.  In  an  intoxi- 
cated subject  the  pupils  are  evenly  dilated,  and  the 
stertorous  breathing  is  absent.  He  can  generally  be 
roused,  though  he  sinks  back  again  into  stupor.  The 
temperature  is  likely  to  be  two  or  three  degrees  below 
normal.  Lay  the  patient  on  the  side,  the  head  some- 
what elevated,  and  induce  vomiting. 

A  person  found  insensible  may  be  suffering  from 
one  of  these  affections,  from  concussion  or  compression 
of  the  brain  following  injury  to  the  head,  or  from  nar- 
cotic poisoning.  In  all  cases,  keep  the  head  cool  and 
the  feet  warm,  and  get  medical  advice  as  soon  as  pos- 
sible. 

Poisons  may  be  classified  as  irritant,  those  destroy- 
ing the  tissues  with  which  they  come  in  contact,  pro- 
ducing death  by  shock  to  the  nervous  system;  narcotic, 
those  producing  insensibility  and  death  by  their  action 
on  the  brain,  without  local  effect;  and  aero-narcotic, 


366  A  TEXT-BOOK  OF  NURSING 

those  which  combine  the  action  of  the  two.  Treatment 
has  three  things  in  view:  to  remove  the  injurious  sub- 
stance, neutralize  its  further  action,  and  remedy  such 
ill  effects  as  it  may  have  already  produced.  The  stom- 
ach is  to  be  evacuated  by  emetics.  You  will  be  able 
to  get  nearly  everywhere,  at  short  notice,  warm  water 
and  salt,  or  ground  mustard,  either  of  which  is  an  ex- 
cellent emetic.  Stir  up  a  tablespoonful  in  a  cup  of  the 
warm  water,  and  give  repeatedly.  The  same  quantity 
of  wine  of  ipecac  in  water,  or  sulphate  of  zinc,  twenty 
grains  at  a  time,  may  be  given.  Tickling  the  back  of 
the  throat  with  the  finger  or  a  feather  will  sometimes 
induce  emesis.  Emetics  should  be  condensed  and  fre- 
quent. Half  a  pint  to  a  pint  at  a  time  is  enough.  Too 
large  a  quantity  may  distend  the  stomach  to  the  point 
of  paralyzing  the  muscular  walls,  and  too  dilute  solu- 
tions will  act  as  purgatives  instead  of  emetics.  It  may 
be  desirable  in  some  cases,  after  the  stomach  has  been 
cleared,  to  evacuate  the  bowels  also,  as  some  of  the 
poison  may  have  passed  into  them.  Do  not  stop  to  dis- 
solve emetics  fully,  but  stir  them  up  in  water  and  give 
as  quickly  as  possible.  After  any  irritant  poison  give 
some  bland  fluid  to  soothe  the  injured  parts.  White  of 
egg,  milk,  mucilage  and  water,  flour  and  water,  gruel, 
olive  or  castor  oil,  may  be  used.  Oil  must  not  be  given 
in  case  of  poisoning  by  phosphorus  or  cantharides.  For 
all  the  acids,  alkalies  are  the  chemical  antidote,  and 
vice  versa.  The  antidote  to  a  poison  is  either  chemical, 
uniting  with  it  to  form  a  harmless  compound,  or  phys- 
iological, correcting  its  effects  upon  the  system. 

"  Be  bold  f 

Be  bold,  be  bold,  and  evermore  be  bold  I 
BE  NOT  TOO  BOLD!" 

Spenser. 


EMERGENCIES,  SURGICAL  AND   MEDICAL     367 


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CHAPTER   XX 

"  Not  by  deeds  that  gain  the  world's  applauses, 
Not  by  works  that  win  thee  world  renown, 
Not  by  martyrdom  or  vaunted  crosses, 

Canst  thou  win  and  wear  the  immortal  crown. 
Daily  struggling,  though  unloved  and  lonely, 

Every  day  a  rich  reward  will  give ; 
Thou  wilt  find  by  hearty  striving  only, 
And  truly  loving,  thou  canst  truly  live." 

H.  W.  Sewall. 

DISEASE  may  terminate  either  by  complete  restora- 
tion to  health,  by  subsidence  into  a  chronic  form,  by  a 
lapse  into  some  other  disease,  or  by  death.  When  the 
seat  of  disorder  is  suddenly  transferred  from  one  part  of 
the  body  to  another,  the  change  is  called  metastasis. 
Convalescence  may  be  abrupt  or  gradual,  it  may  go  on 
steadily,  or  be  delayed  by  complications  or  interrupted 
by  relapse.  Sudden  convalescence  is  most  common  in 
nervous  affections,  while  in  nearly  all  acute  diseases  it 
is  established  by  gradual  resolution. 

The  care  of  a  convalescent  is  not  the  least  weari- 
some kind  of  nursing,  although  it  does  not  involve  the 
hardest  work.  You  miss  the  exciting  interest  which 
sustained  you  during  the  crisis  of  danger,  yet,  even  if 
you  are  already  fatigued,  your  watchfulness  must  not 
be  relaxed,  for  the  patient  will  be  left  more  than  ever 
to  your  responsibility,  while  he  is  more  likely  to  risk 
imprudence  and  relapse.  Convalescents  are  very  apt 
not  to  realize  their  own  weakness  and  to  want  to  do 

371 


372  A  TEXT-BOOK  OP  NURSING 

more  than  they  are  really  able.  You  must  see  that  they 
do  not  overexert  themselves  in  any  way.  A  patient 
beginning  to  improve  will  at  first  be  allowed  to  sit  up 
in  bed,  then  may  be  lifted  to  an  easy  chair  or  a  sofa  for 
a  short  time — perhaps  an  hour  at  first — gradually  in- 
creased each  day.  Then  he  may  walk  across  the  room, 
or  into  the  next  room,  and  be  taken  out  for  a  quiet 
drive  on  a  bright  day.  The  time  when  an  invalid  is 
first  allowed  to  leave  his  bed  is  one  when  special  care  is 
required.  All  the  clothing  should  be  well  aired  and 
warmed.  If  the  patient  has  something  bright  and  pretty 
to  put  on,  it  will  make  him  feel  better,  though  any- 
thing elaborate  and  difficult  to  get  into  is  objection- 
able; everything  should  be  loose,  easy,  and  not  cumber- 
some. A  wrapper  with  a  heavy  train  will  be  enough 
of  a  burden  to  fatigue  a  feeble  woman  and  prevent  her 
from  walking  as  much  as  she  otherwise  might.  Walk- 
ing is  less  fatiguing  than  standing.  The  room  should 
be  warmer  than  when  the  patient  is  in  bed.  Let  him 
sit  where  he  can  see  the  fire,  unless  the  eyes  are  weak, 
but  not  too  near.  To  provide  against  a  draft  under  the 
legs,  put  a  blanket  in  the  easy  chair,  reaching  well  to 
the  floor,  which  can  be  folded  up  over  the  feet.  A  foot- 
stool is  always  desirable. 

When  the  patient  only  sits  up  in  bed,  some  extra 
covering  will  be  needed  about  the  shoulders  and  chest. 
For  this  purpose  a  loose  flannel  jacket  is  much  better 
than  a  shawl,  as  it  does  not  confine  the  arms  or  slip  off. 
The  "  Nightingale "  wrap  is  a  very  convenient  and 
easily  adjusted  shape.  For  this,  two  yards  of  flannel  of 
the  ordinary  width  are  required.  Cut  a  straight  slit 
six  inches  deep,  in  the  middle  of  one  side,  turn  back 
the  points  so  formed  for  a  collar,  and  those  of  the  cor- 
ners farthest  from  it  for  cuffs;  bind  or  pink  it  around 


THE  TERMINATIONS  OP  DISEASE  373 

the  edges,  and  add  buttons  and  buttonholes,  as  illus- 
trated in  the  diagram.  It  can  be  made  as  ornamentally 
or  as  simply  as  desired. 

The  patient,  upon  first  getting  up  from  an  acute 
disease,  should  not  be  allowed  to  receive  visitors,  as 
the  unwonted  exertion  is  in  itself  as  much  of  an  ex- 


ooo  0  0 


Nightingale. 

citement  as  is  safe.  It  is  best  to  have  no  one  in  the 
room  but  yourself  and  your  patient,  unless  you  need  an 
assistant. 

You  should  have  full  authority  on  the  question  of 
visitors,  and  it  will  be  often  your  duty  to  protect  the 
patient  from  his  friends.  Do  not  let  him  feel  obliged 
to  receive  every  one  who  calls.  An  invalid  can  always 
be  politely  excused.  Some  visitors  will  be  unobjection- 
able, and  even  good  for  him,  while  others,  with  equally 
kind  intentions,  will  do  all  the  harm  possible.  Do  not 
let  anybody  stay  too  long,  nor  admit  too  many  at  a  time. 
Three  in  succession  will  be  less  wearisome  than  two  at 
a  time,  who  claim  divided  attention.  Provide  a  seat  for 
the  visitor,  facing  the  patient,  so  that  he  can  see  and 
hear  without  effort.  Do  not  give  the  patient's  easy 
chair,  nor  let  the  visitor  stand  at  the  foot  of  the  bed, 
or  lean  against  it.  A  small  table  at  the  foot  of  the  bed, 
with  a  few  things  on  it,  is  an  excellent  arrangement  to 
25 


374  A  TEXT-BOOK  OP  NURSING 

prevent  this,  and  to  keep  people  from  taking  hold  of 
the  bed  and  jarring  it  as  they  pass. 

See  that  visitors  do  not  smuggle  in  contraband  arti- 
cles. It  is  not  only  in  hospitals  that  there  is  danger  of 
this,  though  it  is  a  most  common  trouble  there.  You 
may  find  all  your  work  undone  by  some  injudicious  gift 
which  you  only  discover  too  late.  A  handful  of  fresh 
flowers,  a  new  picture,  or  some  pretty  decoration  for  the 
room,  is  always  a  better  token  of  remembrance  to  send 
an  invalid  than  delicacies  to  eat,  which  are  very  likely 
to  be  unsuited  for  him. 

No  visitors  should  be  admitted  after  dark,  as  a  rule. 
As  night  approaches,  you  should  try  to  get  the  patient 
into  a  quiet,  unexcited  state  of  mind.  It  is  not  advis- 
able to  hush  every  sound  as  soon  as  he  drops  asleep,  for 
absolute  quiet  is  very  hard  to  maintain,  and  slight  noises 
will  be  less  likely  to  disturb  him  if  he  is  accustomed  to 
sleep  through  ordinary  sounds.  If  you  are  obliged  to 
wake  him,  do  not  rouse  him  suddenly  or  sharply.  You 
will  seldom  have  occasion  to  do  it  at  all.  You  should 
not  wake  a  sleeping  patient  for  anything  unless  by  spe- 
cial orders.  In  the  great  majority  of  cases,  healthy  sleep 
is  a  better  restorative  than  any  you  can  administer. 
This  does  not  apply  to  the  insensibility  of  stupor. 

Before  settling  down  for  the  night,  see  that  every- 
thing likely  to  be  needed  is  where  it  can  be  readily 
found.  Have  food  and  fuel  enough  to  last  through  the 
night;  matches  and  a  candle  at  hand,  if  a  night-light  is 
not  kept  burning.  In  the  latter  case,  see  not  only  that 
the  light  is  carefully  shaded,  but  that  there  are  no  re- 
flections of  it  to  shine  in  the  patient's  eyes.  Dress  your- 
self for  the  night  in  a  warm  wrapper,  not  a  shawl,  and 
easy,  noiseless  slippers.  A  nurse  should  be  warranted 
not  to  snore. 


THE  TERMINATIONS  OF  DISEASE  375 

If  the  patient  expresses  any  wish  to  see  a  clergy- 
man or  a  priest,  he  should  be  sent  for,  especially  if  there 
is  any  apprehension  of  death.  If  he  is  very  sick,  it  is 
no  time  for  religious  exhortation,  and  any  excitement 
should  be  avoided;  but,  if  the  clergyman  has  any  tact 
and  sense  of  propriety,  his  visit  may  be  a  comfort  to 
the  patient,  as  well  as  to  his  friends. 

The  friends  of  the  dying  might  be  spared  much 
anxiety  if  they  realized  how  seldom  the  severance  of 
soul  and  body  is  attended  by  any  agony.  To  many  a 
weary  sufferer  death  comes  as  a  glad  release  from  the 
burden  of  pain,  and  even  where  the  patient  has  clung  to 
life,  and  seemed  to  fear  the  end,  it  comes  almost  al- 
ways peacefully  and  painlessly.  Death  itself — the  last 
ebbing  of  the  vital  force — is  not  painful,  even  though 
intense  suffering  may  have  preceded  it.  Death-bed 
scenes  are  rarely  either  edifying  or  agonizing,  though 
always  solemn. 

Death  approaches  through  one  of  the  three  vital 
organs,  the  heart,  lungs,  or  brain — by  asthenia,  apncea, 
or  coma.  Among  the  signs  of  approaching  dissolution 
are  coldness  of  the  extremities,  a  certain  sharpness  of 
the  features,  a  dusky  shade  about  the  face  and  finger- 
nails, cold  perspiration,  restlessness,  and  muscular 
twitchings  or  stupor. 

Do  not  unnecessarily  alarm  the  friends;  but,  when 
you  are  sure  that  the  end  is  near,  it  is  best  that  they 
should  be  informed.  Disturb  the  dying  as  little  as  pos- 
sible, though  you  must  not  give  up  working  while  there 
is  the  slightest  ground  for  hope.  Note  the  exact  time 
at  which  death  takes  place,  and  take  care  not  to  an- 
nounce it  prematurely.  The  failure  is  sometimes  so 
gradual  as  to  lead  to  error  in  this  respect.  In  a  hos- 
pital, the  attending  physician,  if  not  present,  must  be 


376  A  TEXT-BOOK  OF  NURSING 

notified  at  once.  After  a  few  hours  there  can  rarely  be 
any  doubt  whether  or  not  death  has  taken  place.  The 
only  condition  at  all  likely  to  be  confounded  with  it  is 
that  of  catalepsy,  which  is  most  often  associated  with 
hysteria. 

Shortly  after  death  there  may  be  a  high  rise  of  tem- 
perature, produced  by  chemical  changes  within  the 
body;  but  it  soon  assumes  the  temperature  of  other 
inanimate  objects,  and  the  rigor  mortis  sets  in — a  pecul- 
iar stiffening  of  the  muscles.  As  a  rule,  the  sooner  it 
comes  on,  the  quicker  it  disappears,  leaving  the  limbs 
quite  lax.  Before  it  takes  place,  the  body  should  be 
prepared  for  burial.  Wash  it  with  a  weak  solution  of 
carbolic  acid,  or  chlorinated  soda,  close  the  eyes,  ar- 
range the  lips  naturally,  and  smooth  the  hair.  If  there 
is  any  difficulty  in  keeping  the  eyes  shut,  put  a  tiny 
wisp  of  cotton  upon  each  eyeball  under  the  lids.  This 
will  keep  them  from  slipping.  To  keep  the  mouth  shut, 
put  a  firm  wedge  under  the  jaw,  resting  in  the  hollow 
of  the  throat,  not  a  bandage  about  the  head,  which  is 
difficult  to  adjust,  and  always  leaves  marks  of  pressure. 
After  the  jaw  is  firmly  set,  the  wedge  can  be  removed. 
Straighten  the  limbs,  tying  the  feet  together  with  a 
broad  tape  or  a  bandage.  Pack  all  the  orifices  of  the 
body  with  absorbent  cotton,  or  coarse  salt,  to  prevent 
discharges,  and  bind  a  cloth  firmly  around  the  hips, 
putting  it  on  like  a  child's  diaper.  Over  this  can  be 
any  clothing  desired;  a  clean  night-dress  or  a  simple 
shroud  is  more  suitable  than  anything  else.  Cover  face 
and  all  with  a  sheet.  If  the  death  occurs  in  a  hospital 
ward,  all  this  must,  of  course,  be  done  behind  screens. 
Do  not  send  for  the  stretcher  to  remove  the  body  until 
everything  is  quite  ready,  and  then  have  it  taken  away 
as  quickly  and  quietly  as  possible.  Have  the  door  of 


THE  TERMINATIONS  OP  DISEASE  377 

the  opposite  ward  closed.    See  that  the  patient's  name 
is  on  the  shroud. 

In  a  private  house,  the  final  arrangements  will  all 
be  put  into  the  hands  of  an  undertaker,  but  it  is  quite 
likely  the  friends  will  wish  you  to  superintend  them, 
and  perhaps  even  lay  out  the  body.  If  it  is  to  be  kept 
for  any  length  of  time,  it  must  be  packed  in  ice.  After 
twenty-four  hours  on  ice,  the  body  assumes  a  much 
more  natural  appearance.  Any  slight  discolorations  can 
be  made  less  conspicuous  by  dusting  them  over  with 
toilet  powder.  After  the  body  has  been  taken  out,  the 
room  must  be  put  in  order,  all  the  appliances  of  sickness 
removed,  the  bedding  sent  out  to  be  disinfected,  and 
the  windows  left  wide  open  for  twelve  hours. 

"  The  world  goes  on;  and  happiest  is  he 
Who  in  such  wise  wins  immortality, 
That,  should  he  sleep  forever  in  the  grave, 
His  work  goes  on  and  helps  the  world  to  save." 

J.  W.  Chadmck. 


VOCABULARY 


Abnormal.    Unnatural. 

Abortion.    Premature  expulsion  of  a  foetus. 

Abscess.    A  circumscribed  cavity  containing  pus. 

Acids.    Chemical  agents  which  redden  vegetable  blues.    They 
are  usually  sour  in  taste. 

Acronarcotic.    Combining  irritant  and  narcotic  action. 

Actual  Cautery.    A  hot  iron  used  in  cauterization. 

Acute.    Sharp.    A  disease  having  rapid  progress  and  short  dura- 
tion is  said  to  be  acute. 

Adhesion.    Sticking  together  of  unlike  particles. 

Albuminuria.     The  presence  of  albumin  in  the  urine. 

Alkalies.    Substances  which  have  the  power  of  restoring  the 
blues  reddened  by  acids. 

Alimentary  Canal.    The  tube  extending  from  the  mouth  to  the 
anus. 

Alterative.    A  medicine  producing  gradual  change. 

Amenorrhcea.    Absence  of  the  menstrual  discharge. 

Amorphous.    Without  regular  shape. 

Amylaceous.    Starchy. 

Anaemia.     A  lack  of  red  corpuscles  in  the  blood. 

Anaesthesia.    Loss  of  sensibility. 

Anasarca.    An  accumulation  of  serum  in  the  cellular  tissue. 

Anastomosis.    Communication  of  vessels. 

Anatomy.    The  science  that  describes  the  form  and  position  of 
parts. 

Aneurism.    A  dilatation  or  rupture  of  an  artery. 

Anodyne.    Medicine  to  allay  pain. 

Antacid.    A  remedy  against  acidity. 

Anthelmintic.    A  remedy  against  worms. 

Antipyretic.    Opposed  to  fever. 

379 


380  A  TEXT-BOOK  OF  NURSING 

Antiseptic.    Preventing  putrefaction. 

Anus.    The  opening  at  the  inferior  extremity  of  the  rectum. 

Aphasia.    Loss  of  the  power  of  speech. 

Aphonia.    Loss  of  voice. 

Aphthae.    Small  white  ulcers  of  the  mucous  membrane. 

Apnoea.    Absence  of  breath. 

Apyrexia.    Absence  of  fever. 

Areola.    1.  A  circle  around  the  nipple.    2.  An  inflamed  circle 

around  an  eruption. 

Areolar  Tissue.    Cellular  or  connective  tissue. 
Articulation.    The  joining  of  bones. 
Ascites.    A  collection  of  serous  fluid  in  the  abdomen. 
Asepsis.    Absence  of  putrefactive  germs. 
Asphyxia.     Without  pulse.    Suspended  animation. 
Assimilation.    The  process  by  which  bodies  appropriate  and 

transform  other  matters  into  their  own  substance. 
Asthenia.     Want  of  strength.    Exhaustion. 
Astringent.    Having  the  power  of  contracting  organic  tissues. 
Atrophy.     Wasting  away. 
Auscultation.    The  act  of  listening,  as  applied  to  the  heart  and 

lungs. 
Autopsy.    The  examination  of  a  body  after  death. 

Ballottement.  The  falling  back  of  the  foetus  in  utero  when  dis- 
placed by  the  examining  finger. 

Benign.    Of  a  mild  character. 

Bistoury.    A  small,  narrow-bladed  knife  used  in  surgery. 

Borborygmus.    A  rumbling  in  the  intestines. 

Bougie.  An  instrument,  shaped  like  a  candle,  for  dilating  mu- 
cous canals. 

Bulimia.    Abnormal  appetite. 

Bursa.    A  small  sac  containing  fluid,  found  near  the  joints. 

Cachexia.    A  generally  bad  condition  of  the  body. 

Cadaver.    A  dead  body. 

Csesarean  Section.    The  operation  of  removing  a  child  from  the 

uterus  by  incision  through  the  abdomen. 
Calcareous.    Having  the  nature  of  lime. 
Calculus.    A  stone. 
Callus.    The  new  material  thrown  out  to  unite  the  fracture  of  a 

bone. 


VOCABULARY  381 

Capillary.    Hair-like  in  size. 

Capsule.  1.  A  membranous  expansion  inclosing  a  part.  2.  A 
gelatinous  envelope  in  which  medicines  may  be  given. 

Carcinoma.    Cancer. 

Cardiac.    Pertaining  to  the  heart. 

Caries.    Ulce  ration  of  bone. 

Carminative.  A  remedy  which  allays  pain  by  causing  the  ex- 
pulsion of  flatus  from  the  alimentary  canal. 

Cartilage.    A  smooth,  elastic  tissue,  somewhat  softer  than  bone. 

Catalepsy.  A  disease  in  which  there  is  sudden  suspension  of  the 
senses  and  of  the  will,  the  body  remaining  in  whatever  posi- 
tion it  is  placed. 

Catamenia.    The  menstrual  discharge. 

Cataplasm.    A  poultice. 

Cataract.    An  opacity  of  the  crystalline  lens. 

Catarrh.    Increased  secretion  from  a  mucous  membrane. 

Cathartic.  A  medicine  producing  free  discharges  from  the 
bowels. 

Caustic.    A  substance  which  burns  living  tissues. 

Cellulitis.     Inflammation  of  the  cellular  or  connective  tissue. 

Cholagogue.    A  medicine  increasing  the  flow  of  bile. 

Chorea.    St.  Vitus's  dance. 

Chronic.    Of  long  duration. 

Chyluria.    Milky  urine. 

Cicatrix.     A  scar. 

Cilia.    Hair-like  projections. 

Circumscribed.     Distinctly  limited. 

Clinical.    At  the  bedside. 

Clyster.    An  enema. 

Coagulation.    Curdling  of  a  fluid. 

Coaptation.  Fitting  together.  The  act  of  adapting  to  each 
other  the  ends  of  a  broken  bone. 

Cohesion.    The  force  which  holds  like  particles  together. 

Collapse.    Complete  prostration  of  the  vital  powers. 

Colloid.    Jelly-like. 

Collyrium.    Eye-wash. 

Colostrum.    The  first  milk  secreted  after  confinement. 

Coma.    A  state  of  profound  insensibility. 

Comminuted.    Broken  in  small  pieces. 

Confluent.    Running  together. 

Congenital,    Existing  from  birth. 


382  A  TEXT-BOOK  OF  NURSING 

Congestion.    The  accumulation  of  blood  in  any  organ. 

Connective  Tissue.  A  lace-work  of  fibrous  threads  which  ex- 
tends through  all  the  organs  of  the  body,  binding  their-  ele- 
ments together. 

Contagion.    The  communication  of  disease  by  contact. 

Continuity.    An  uninterrupted  connection  of  parts. 

Centra-indication.    An  indication  against. 

Convulsions.    Involuntary  contractions  of  the  muscles. 

Coryza.  Inflammation  of  the  mucous  membrane  of  the  nose, 
with  free  discharge. 

Counter-irritation.  Irritation  excited  in  one  part  of  the  body 
to  relieve  another. 

Crepitation.  1.  The  sound  of  air  passing  through  fluid.  2.  The 
grating  made  by  rubbing  together  the  ends  of  a  broken  bone. 

Crepitus.     Crepitation.    Chiefly  used  in  the  latter  sense. 

Crisis.    The  turning-point  in  a  disease. 

Cumulative.    Increasing  by  successive  additions. 

Cyanosed.    Blue. 

Cystitis.    Inflammation  of  the  bladder. 

Decoction.    1.  The  operation  of  boiling  certain  ingredients  in  a 

fluid.    2.  The  result  of  such  boiling. 
Decomposition.     Separation  of    a  body    into    its   component 

parts. 

Decubitus.    Manner  of  lying. 
Defecation.    The  discharge  of  fecal  matter. 
Defervescence.    The  decline  of  fever. 
Dejection.    The  act  of  emptying  the  bowel. 
Demulcent.    Soothing. 
Deodorant.    Destroying  odors. 
Desquamation.    Scaling  off  of  the  skin. 
Desiccation.    Drying  up. 

Determination.    Strong  and  rapid  flow  of  fluid  to  any  part. 
Diagnosis.    Distinguishing  one  disease  from  another. 
Diaphoretic.    A  medicine  which  excites  perspiration. 
Diaphragm.    The  large  muscle  separating  the  chest  from  the 

abdomen. 
Diastole.    The  dilatation  of  the  heart  and  arteries  on  entrance 

of  the  blood. 

Diathesis.    A  peculiar  disposition  or  condition  of  the  system. 
Dicrotic.     Rebounding. 


VOCABULARY  383 

Dietetics.    A  branch  of  medicine  comprising  rules  of  diet. 
Digestion.    Dissolving.     The  change  which  food  undergoes  in 

the  alimentary  canal. 
Digital.    Pertaining  to  the  fingers. 
Dilatation.    Expansion  in  all  directions. 
Discrete.    Distinct. 

Disinfectant.    An  agent  which  destroys  septic  germs. 
Dislocation.    Displacement. 
Distal.    Farthest  from  the  heart. 
Diuresis.    An  increased  excretion  of  urine. 
Dorsal.    Pertaining  to  the  back. 
Douche.    A  column  or  shower  of  fluid. 
Drastic.    Strongly  active. 
Duct.    Any  tube  or  canal. 

Dysmenorrhoea.    Difficult  or  painful  menstruation. 
Dyspepsia.    Difficult  digestion. 
Dysphagia.    Difficulty  in  swallowing. 
Dyspnoea.    Difficulty  in  breathing. 
Dysuria.    Difficult  and  painful  passage  of  urine. 

Ecchymosis.    An  extravasation  of  blood  into  connective  tissue. 

Effervescence.  The  escape  of  gas  through  liquid,  independently 
of  heat. 

Effusion.    A  pouring  out. 

Electrolysis.    Decomposition  by  electricity. 

Embolus.     A  plug  obstructing  a  blood-vessel. 

Embrocation.    A  liniment. 

Embryo.  The  fecundated  germ  in  its  early  stages  of  develop- 
ment. 

Emesis.    The  act  of  vomiting. 

Emetic.    Producing  emesis. 

Emmenagogue.  A  medicine  promoting  the  menstrual  dis- 
charge. 

Emollients.    Substances  which  relax  and  soften  the  tissues. 

Emphysema.     Air  escaped  into  the  connective  tissue. 

Emulsion.    A  mixture  of  oil  and  water. 

Endemic.    Peculiar  to  a  locality. 

Enema.    A  fluid  preparation  for  injection  into  the  rectum. 

Enteric.    Intestinal. 

Enuresis.    Inability  to  hold  the  urine. 

Epidemic.    A  disease  attacking  many  people. 


384  A  TEXT-BOOK  OP  NURSING 

Epigastrium.    The  region  near  the  stomach. 
Epispastics.    Blistering  agents. 
Epistaxis.    Haemorrhage  from  the  nose. 
Eructation.    Bringing  up  gas  from  the  stomach. 
Escharotic.    A  substance  which  occasions  sloughing. 
Exacerbation.    An  increase  in  the  symptoms  of  a  disorder. 
Exanthemata.     The  eruptive  fevers. 
Excoriation.    An  abrasion  of  the  skin. 
Excretion.    The  throwing  off  of  waste  matter. 
Expectant.    Treatment  by  leaving  disease  to  nature. 
Expectorant.    A  medicine  facilitating  the  expulsion  of  sputa. 
Extirpation.    Complete  removal. 
Extra-uterine.    Outside  the  uterus. 

Extravasation.    The  escape  of  the  contents  of  vessels  into  the 
surrounding  tissues. 

Peaces.    Evacuations  from  the  bowels. 

Fasciae.    Fibrous  membranes  binding  parts  together. 

Fauces.    The  throat. 

Febrile.    Pertaining  to  fever. 

Fistula.    A  narrow  canal  lined  by  false  membrane. 

Flatulence.    Gas  in  the  alimentary  canal. 

Fluctuation.    The  undulation  of  fluid  as  felt  by  the  hands. 

Foetus.    The  young  of  any  animal  in  the  uterus. 

Fontanelles.     Spaces  between  the  cranial  bones  in  the  young 

child. 

Fumigation.    Charging  the  air  with  gas  or  vapor. 
Function.    The  office  or  duty  of  an  organ. 
Fundus.    The  base. 

Galactorrhoea.     An  excessive  flow  of  milk. 
Gall-stones.     Biliary  concretions. 
Gangrene.    The  first  stage  of  mortification. 
Gastric.    Pertaining  to  the  stomach. 
Genital.    Pertaining  to  the  function  of  reproduction. 
Germ.    The  undeveloped  rudiment  of  a  new  being. ; 
Gestation.    Pregnancy. 

Gland.    An  organ  having  the  function  of  secretion. 
Globus  hystexicus.    The  sensation  as  of  a  ball  in  the  throat. 
Granulations.    Small  red  eminences  forming  on  the  surfaces  of 
suppurating  wounds. 


VOCABULARY  385 

Haematemesis.    Vomiting  of  blood. 

Heematuria.    Blood  in  the  urine. 

Haemoptysis.    Spitting  of  blood. 

Haemorrhage.    The  escape  of  blood  from  its  vessels. 

Haemostatic.     An  agent  to  stop  haemorrhage. 

Hemicrania.     Pain  in  one  side  of  the  head. 

Hemiplegia.     Paralysis  of  the  lateral  half  of  the  body. 

Hepatic.    Relating  to  the  liver. 

Hernia.    The  displacement  and  protrusion  of  a  viscus  from  its 

natural  cavity. 

Histology.    The  minute  anatomy  of  the  tissues. 
Hydragogue.    A  medicine  causing  watery  evacuation. 
Hydrated.    Combined  with  water. 
Hydropathy.    Water-cure. 
Hygiene.    The  preservation  of  health. 
Hypersemia.    An  excess  of  blood  in  the  capillaries. 
Hyperaesthesia.     Excessive  sensibility. 
Hyperpyrexia.    Very  high  fever. 
Hypnotic.    Sleep-producing. 
Hypodermic.    Subcutaneous. 

Impacted.    Wedged  in. 

Imperforate.    Without  an  opening. 

Incontinence.    Inability  to  restrain. 

Incubation.  Hatching.  The  period  between  the  reception  of  a 
poison  and  the  appearance  of  the  symptoms. 

Indolent.    Giving  little  or  no  pain. 

Induration.    Hardness. 

Infection.    The  communication  of  disease. 

Infiltration.    The  escape  of  fluids  into  connective  tissue. 

Infusion.  1.  The  process  of  steeping  a  substance  in  fluid.  2. 
The  resulting  liquor. 

Inoculation.    Injection  of  a  virus  into  the  body. 

Insertion.  The  attachment  of  one  part  to  another.  Of  a 
muscle,  the  movable  point  toward  which  its  force  is  di- 
rected. 

Insomnia.    Sleeplessness. 

Inspiration.    Drawing  in  the  breath. 

Intermittent.    Ceasing  at  intervals. 

Intravenous.    Within  a  vein. 

Inunction.    The  rubbing  in  of  an  ointment 


386  A  TEXT-BOOK  OF  NURSING 

Involution.    The  gradual  return  of  parts  to  a  normal  size  and 

condition. 

Irreducible.    Not  to  be  replaced. 
Irrigation.    Regular  and  continuous  washing  of  a  part. 
Irritation.    Excess  of  vital  movement,  usually  manifested  by 

increase  of  circulation  and  sensibility. 
Isothermal.    Having  the  same  temperature. 

Jaundice.    Yellowness  resulting  from  some  obstruction  in  the 
course  of  the  bile. 

Laceration.    A  breach  made  by  tearing. 

Lactation.    Suckling. 

Laparotomy.    Opening  the  abdomen. 

Lateral    On  the  side. 

Laxative.    A  gently  evacuating  medicine. 

Lesion.    Injury  or  disorder. 

Lethargy.    Stupor. 

Leucorrhcea.    A  white  vaginal  discharge. 

Ligation.    Tying. 

Ligature.    The  thread  used  for  tying  a  vessel. 

Litmus.    A  vegetable  blue  pigment.    Acids  turn  it  red. 

Lochia.     The  discharge  of  blood  and  serum  following  child- 

birth. 

Luxation.    A  dislocation. 
Lymph.    1.  The  fluid  contained  in  the  lymphatic  vessels.    2. 

The  fluid  poured  out  in  adhesive  inflammation. 

Maceration.    Making  soft  by  steeping. 
Malaise.    Indisposition. 
Malaxation.    Kneading. 
Malformation.     Irregularity  in  structure. 
Malignant.    Serious  in  character. 
Malingery.    Feigning  disease. 
Malnutrition.    Poor  nourishment. 
Marasmus.    Wasting  away. 

Median  Line.    An  imaginary  line  dividing  the  body  longitudi- 
nally into  two  equal  parts. 
Menorrhagia.    Excessive  menstruation. 
Menstrual.    Monthly. 
Metastasis.    A  change  in  the  seat  of  a  disease. 


VOCABULARY  387 

Miasm.    A  poisonous  emanation. 

Micturition.    The  act  of  passing  water. 

Miscarriage.    Premature  expulsion  of  a  foetus. 

Mole.    1.  A  fleshy  growth  in  the  uterus.  2.  A  rounded  fatty  nevus 

Morbid.    Diseased. 

Morbific.    Causing  disease. 

Moribund.    About  to  die. 

Mortification.    Loss  of  life  in  a  part. 

Mucus.    A  viscid  fluid  secreted  by  mucous  membranes. 

Multipara.    A  woman  who  has  given  birth  to  several  children. 

Naevus.     A  birth-mark. 

Narcosis.    The  condition  produced  by  narcotic  substances. 

Narcotic.    Stupefying. 

Nares.    The  nostrils. 

Nates.    The  buttocks. 

Nephritic.    Pertaining  to  the  kidneys. 

Neuralgia.     Non-inflammatory  pain  in  a  nerve. 

Neurasthenia.    Nervous  debility. 

Neuroses.    Diseases  of  the  nervous  system. 

Normal.    Natural. 

Nucleus. 

Obstetrics.    Midwifery. 

Occipital.    Relating  to  the  back  of  the  head. 

Occlusion.    Shutting  up. 

QSdema.    Swelling  from  the  infiltration  of  serum  into  the  areolar 

tissue. 

Officinal.    Authorized  by  the  pharmacopoeia. 
Opiate.    A  medicine  containing  some  form  of  opium. 
Organ.    Part  of  a  living  being  exercising  some  special  function. 
Origin  (of  a  muscle).     Its  fixed  or  central  attachment. 
Orthopcedic.    Correcting  deformity. 
Orthopncea.    Inability  to  breathe  lying  down. 
Osmosis.    The  passage  of  fluid  through  a  porous  solid. 
Osseous.    Bony. 

Ossification.    Conversion  into  bone. 
Ovulation.    The  formation  of  ovules  in  and  their  discharge  from 

the  ovary. 

Ovum.    The  embryo  and  its  membranes. 
Oxidation.    Combining  with  oxygen. 


388  A  TEXT-BOOK  OP  NURSING 

Ozsena.    An  offensive  discharge  from  the  nose. 
Ozone.    A  peculiar  modification  of  oxygen. 

Palpation.     1.  The  sense  of  touch.     2.  Exploring  diseases  by 

pressure  with  the  hand. 
Panacea.    A  universal  remedy. 

Papilla.    1.  The  nipple.    2.  A  small  eminence  on  the  surface. 
Paracentesis.     The  operation  of  tapping. 
Paralysis.    Loss  of  voluntary  motion  or  sensation. 
Paraplegia.    Paralysis  of  the  lower  half  of  the  body. 
Parasiticide.    An  agent  that  kills  parasites. 
Paroxysm.    A  periodical  attack  or  exacerbation  of  a  disorder. 
Pathogenic.    Producing  disease. 
Pathology.    The  physiology  of  disease. 
Patulous.     Wide  open. 

Percussion.    Striking  on  a  body  to  elicit  sounds. 
Peristaltic.    Undulating  or  worm-like.    Applied  particularly  to 

the  motions  of  the  alimentary  canal. 
Pessary.    An  instrument  to  support  the  uterus. 
Petechiee.    Spots  on  the  skin  occurring  in  the  course  of  severe 

fevers. 

Pharmaceutics.     The  science  of  preparing  medicines. 
Physiology.    The  science  of  life. 
Pipette.    A  small  glass  tube. 
Placenta  Praevia.     The  attachment  of  the  placenta  over  the 

mouth  of  the  uterus. 
Plastic.    Formative. 

Polypus.    A  kind  of  tumor  occurring  in  mucous  membranes. 
Post  mortem.    After  death. 
Primipara.    A  woman  who  bears  her  first  child. 
Process.    An  eminence  of  bone. 

Prognosis.    A  prediction  of  what  course  a  disease  will  take. 
Prolapse.    A  falling  down. 
Prophylaxis.     Prevention. 
Proximal.    Nearest  the  heart. 
Ptyalism.    Salivation. 
Purgative.    Cathartic. 
Purulent.    Having  the  character  of  pus. 
Pustule.     A  minute  abscess. 
Pyaemia.    Contamination  of  the  blood  by  pus. 
Pyrexia.    Fever. 


VOCABULARY  389 

Quarantine.    Enforced  isolation  as  a  preventive  of  contagion. 
Quickening.     The  first  movements  of  the  foetus  felt  in  the 
uterus. 

Bales.     Sounds  in  the  air-passages  produced  by   air  passing 

through  fluid. 

Rectification.    The  process  of  refining  liquids. 
Reduction.    The  restoring  of  displaced  parts. 
Recuperative.    Tending  to  recovery. 
Refrigerant.    Producing  cold. 
Regimen.    Regulation  of  diet. 

Regurgitation.    Throwing  back  a  portion  of  the  contents. 
Relapse.    A  return  of  disease. 

Relaxation.    Remitting  tension.    Opposed  to  contraction. 
Remission.    Abatement  of  symptoms. 
Resolution.    Gradual  disappearance  of  a  disease. 
Rigor.    A  chill. 

Rigor  mortis.    A  stiffening  of  the  muscles  occurring  after  death. 
Rubefacient.    Making  red. 

Sac.    A  bag  or  pouch. 

Saccharine.    Containing  sugar. 

Salivation.    Excessive  secretion  of  saliva. 

Saturation.    The  union  of  one  substance  with  another  until  it 

can  take  no  more. 

Scarification.    Making  several  small  incisions. 
Scybala.    Hard  lumps  of  fecal  matter. 
Secretion.    The  process  by  which  substances  are  separated  from 

the  blood. 
Secundines.    The  placenta  remaining  in  uterus  after  the  birth 

of  the  child. 
Sedative.    Quieting. 
Sepsis.    Putrefaction. 
Septic.    Producing  putrefaction. 
Sequelae.     Morbid  phenomena  resulting  from  disease. 
Shock.    Sudden  depression  of  vital  powers. 
Show.    A  vaginal  discharge  occurring  just  before  labor. 
Sinapism.    A  mustard  plaster. 
Singultus.    Hiccough. 

Sinus.    Any  cavity  the  interior  of  which  is  larger  than  the  opening. 
Slough.    A  dead  portion  separating  from  the  living. 
26 


390  A  TEXT-BOOK  OP  NURSING 

Sordes.  An  accumulation  of  the  secretions  of  the  mouth  upon 
the  teeth. 

Spasm.    An  involuntary  muscular  contraction. 

Speculum.    An  instrument  for  dilating  cavities. 

Sphincter.    A  circular  muscle  constricting  a  natural  opening. 

Sporadic.    Occurring  in  single  or  scattered  cases. 

Sputum.    Matter  spit  out. 

Stercoraceous.    Fecal. 

Stertor.    A  deep  snoring  sound  accompanying  inspiration. 

Stethoscope.  A  tube  for  conveying  sounds  from  the  chest  to 
the  ear. 

Strangury.    Slow  and  painful  passage  of  urine. 

Stricture.    Contraction  of  a  duct  or  tube. 

Stupe.    The  cloth  used  in  fomentations. 

Stupor.    Profound  unconsciousness. 

Styptic.    Astringent. 

Subcutaneous.    Under  the  skin. 

Subsultus.    Muscular  twitching. 

Sudoriferous.    Sweat-bearing. 

Suppository.  Medicine  in  a  solid  form  intended  for  introduc- 
tion into  the  rectum. 

Suppression.    The  stoppage  of  a  secretion  or  discharge. 

Suppuration.    The  formation  of  pus. 

Sutures.  1.  The  articulations  of  the  bones  of  the  skull.  2. 
Stitches  for  holding  together  the  edges  of  a  wound. 

Syncope.    Fainting. 

Syphilis.    An  infectious  venereal  disease. 

Systemic.    Pertaining  to  the  body  generally. 

Systole.    The  contraction  of  the  heart  and  arteries. 

Tactile.    Relating  to  the  sense  of  touch. 

Tampon.    A  plug. 

Tenesmus.     Frequent,  vain,  and  painful  efforts  to  evacuate  the 

bowel. 

Tension.    State  of  being  stretched. 
Tent.    A  cylinder  for  dilating  parts. 

Tetanus.    A  disease  characterized  by  continuous  muscular  spasm. 
Therapeutics.    The  treatment  of  disease. 
Thoracic.    Belonging  to  the  chest. 

Thrombosis.    The  obstruction  of  a  blood-vessel  by  a  clot. 
Tidal  Air.    The  air  expired  and  inspired  in  ordinary  respiration. 


VOCABULARY  391 

Tincture.     A  solution  in  spirit. 

Tissue.    The  peculiar  structure  of  a  part. 

Tone.    A  proper  state  of  tension  or  firmness. 

Torsion.    Twisting. 

Toxic.     Poisonous. 

Transfusion.    Process  of  transferring  blood  or  salt  solution  into 

the  veins. 

Traumatic.     Resulting  from  a  wound. 
Trituration.     Reducing  to  a  fine  powder. 
Tubercle.    A  deposit  of  degenerate  matter  in  the  substance  of 

organs. 

Tumefaction.    Swelling. 
Tumor.    A  morbid  enlargement. 
Tympanites.    Oistention  of  the  abdomen  by  gas. 

Ulcer.    A  solution  of  continuity  of  the  soft  parts  resulting  from 

perverted  nutrition. 
Unguent.    An  ointment. 
Uraemia.     Poisoning  by  urea  in  the  blood. 
Urea.    The  nitrogenous  constituent  of  the  urine. 
Utero-gestation.    Pregnancy. 

Vaccination.    Inoculation  with  the  virus  of  cow-pox. 
Vascular.    Full  of  vessels. 
Venereal.    Pertaining  to  sexual  intercourse. 
Venesection.    Blood-letting  by  opening  a  vein. 
Vermifuge.    Driving  out  worms. 

Vernix  Caseosa.    A  fatty  deposit  found  on  the  foetus  or  new- 
born child. 
Vertigo.    Dizziness. 
Vesicant.    A  blistering  agent. 
Vesicle.    A  very  small  blister. 
Viable.    Sufficiently  developed  to  live. 
Virus.    A  morbid  poison. 
Viscera.    The  internal  organs. 
Vital.    Pertaining  to  life. 
Vivisection.    The  dissection  of  a  live  animal 

Wisdom  Teeth.    The  last  of  the  true  molars. 
Wound.    A  solution  of  continuity  in  the  soft  parts  resulting  from 
injury. 

Zymotic.    Resulting  from  fermentation. 


INDEX 


Abbreviations,  138. 
Abortion,  270. 
Abscess,  237. 
Absorbent  cotton,  244. 
Accidents,  335. 
Acids,  367. 

burns   from,   357. 
Adhesions,  52. 
Affusion,  82. 
After-pains,  272. 
Albuminoids,  173. 
Alkalies,  367. 
Anaesthetics,  250. 
Anastomosis,  51. 
Anchylosis,  205. 
Aneurism,  313. 
Angina  pectoris,  313. 
Antidotes,  367. 
Antipyretics,  60. 
Antiseptics,  225,  241. 
Apnosa,  66. 
Apoplexy,  365. 
Appendicitis,  314. 
Appetite,  119. 
Arteries,  49. 

chart  of,  339. 
Ascites,  312. 
Asepsis,  241. 
Asphyxia,  66,  360. 
Asthma,  308. 
Attitudes,  112. 

characteristic,  116. 

Bacteria,  223. 
Ballottement,  270. 
Bandages,  205-222. 

in  haemorrhage,  218. 

plaster,  202. 


Baths,  78. 

babies,  291,  297. 
Bedding,  31. 
Beds,  28. 

Bedside  notes,  123. 
Bed-sores,  39. 

Bichloride  of  mercury,  228, 242. 
Bites,  355. 

Bladder,  to  wash,  100. 
Blisters,  164. 
Blood,  44. 

Blood-poisoning,  252,  265. 
Blood-vessels,  49. 
Blue  baby,  47. 
Bones,  192. 

Brand  method  of  bathing,  80. 
Breasts,  care  of,  282. 
Bright's  disease,  317. 
Bronchitis,  308. 
Burns,  235,  356. 

Callus,  201. 

Canal,  alimentary,  108. 

Capillaries,  49. 

Carbolic  acid,  242. 

Cardiac  diseases,  312. 

Catarrh,  306. 

Catheterization,  98. 

Cauterization,  345. 

Chemical  elements,  in  air,  65. 

in   food,    172. 
Chicken-pox,  303. 
Chilblains,  363. 
Children,  diseases  of,  289. 
Chills,  116. 
Cholera,  Asiatic,  326. 

infantum,  301. 

morbus,  315. 

393 


394 


A  TEXT-BOOK  OP  NURSING 


Chorea,  322. 
Circulation  of  blood,  44. 
Cleanliness,  of  person,  6,  76. 

of  ward,  24. 

surgical,  239,  247. 
Clergy,  visits  of,  375. 
Clothing,  changing,  76,  336. 

disinfecting,  228. 

for  convalescent,   373. 

for  infant,  273,  292. 
Cold  applications,   161. 
Colic,  intestinal,  316. 

in  infant,  299. 

hepatic,  316. 

renal,  318. 
Collyria,  162. 
Coma,  122. 

Compress,   graduated,   340. 
Congestion,  51. 
Consciousness,     disorders     of, 

122. 
Constipation,  120. 

in  child,  300. 

Contagious  cases,  care  of,  225. 
Contusions,  353. 
Convalescents,  371. 
Convulsions,  364. 

in  child,  301. 

puerperal,  287. 
Condy's  fluid,  228. 
Coryza,  307. 
Counter-irritants,  163. " 
Couveuse,  290. 
Crepitus,  200. 
Croup,  301. 

Cumulative  action,  134. 
Cupping,  167. 
Cystitis,  96-100. 

Dead,  care  of,  376. 
Death,  375. 
Delirium,  324. 

tremens,  325. 
Dentition,  295. 
Diabetes,  316. 
Diarrhoea,   300. 
Digestion,  178. 
Diphtheria,  325. 
Disinfectants,  225-227. 
Dislocations,  204,  352. 
Dosage,  139. 


Douche,  82. 

nasal,  167. 

vaginal,  263. 
Drainage  tubes,  238. 
Draw-sheets,  31. 
Dressings,  surgical,  240. 
Dropsy,  312. 
Drowning,  361. 
Drugs,  care  of,  134. 

list  of,  139. 
Dusting,  24. 
Dysentery,  315. 
Dyspepsia,  313. 
Dyspnoea,  66. 

Eczema,  319. 
Electricity,  324. 
Emergencies,  335. 
Emetics,  366 
Enemata,  101. 
Epilepsy,  364. 
Erysipelas,  252. 
Erythema,  318. 
Eye,  in  disease,  117. 

Facial  expression,  113. 

Fainting,  337. 

Feeding  the  helpless,  176. 

the  infant,  292. 

by  force,  132. 
Fever,  56. 
Fire,  356. 
Fomentations,  159. 
Food,  172. 

for  infant,  292. 
Foot-bath,  83. 

Foreign    matter    in    the    ear, 
358. 

in  the  eye,  357. 

in  the  nose,  359. 

in  the  throat,  359. 

in  a  wound,  238. 
Formaldehyde,  232. 
Fractures,  199. 
Friction,  87. 
Frost-bites,  236,  363. 
Fumigation,  231. 
Furniture  of  sick-room,  17. 

Gargles,  166. 
Gauze,  244. 


INDEX 


395 


Gastritis,  313. 
Germicides,  241. 
Granulation,  237. 
Gynaecology,  260. 

Haemorrhage,  121,  337. 

internal,  285,  348. 

in  typhoid,  328. 

post-partum,  284. 

uterine,  265,  350. 
Hair,  care  of,  77. 
Healing,  modes  of,  236. 
Health,  1. 

Hearing,  disturbances  of,  118. 
Heart,  46. 
Hernia,  363. 
Herpes,  319. 
Hiccough,  115. 
Hot  applications,  161. 
Hydrogen  peroxide,  243. 
Hydrocephalus,  305. 
Hypodermic   injections,    127. 
Hysteria,  323. 

Ice,  161. 

Incontinence  of  urine,  96. 

in  child,  301. 

Incubation,  period  of,  224. 
Indigestion,  313. 
Infant,  care  of,  289. 
Infection,  224. 
Inflammation,  52. 
Influenza,  307. 
Inhalation,  129. 
Insanity,   324. 

Insensible,  person  found,  365. 
Instruments,  care  of,  246. 
Insufflation,  167. 
Intestinal  canal,   101. 

obstruction,   314. 
Inunction,   163. 
Involution,  272. 
Icdoform,  243. 

Knots,  346. 

Labor,  271. 
Laparotomy,  253. 
Laryngitis,  309. 
Leeches,  168. 
Ligatures,  244. 


Lightning  stroke,  362. 
Lime,  burns  from,  357. 
Liniments,  163. 
Locpmotor  ataxia,  322. 
Lotions,  162. 
Lungs,  62. 

Malaria,  333. 
Massage,  85. 
Measles,  303. 

German,  304. 
Measures,  136. 
Medicines,  125. 
Meigs's  mixture,  294. 
Meningitis,  322. 

in  child,  304. 
Metric  system,  136. 
Milk,  181. 

Miscarriage,  264,  270. 
Moisture  in  air,  73. 
Mouth,  in  disease,  118. 

care  of,  119. 
Moving  patients,  36. 
Mumps,  303. 
Mustard  as  an  emetic,  366. 

poultice,  159. 

Narcotics,  133. 
Nausea,  119,  129. 
Neuralgia,  321. 
Neuritis,  320. 
Nightingale  wrap,  373. 
Night  nursing,  374. 
Noise,  18. 
Nose-bleed,  350. 
Nourishment,  173. 

rectal,  258. 
Nurses,  2. 

surgical,  247. 

Observation  of  symptoms,  110. 
Obstetrics,  268. 
CEdema  of  lungs,  114. 

of  tissues,  312. 
Ointments,  163. 
Operating-room,  249,  255. 
Operating  cases,  247. 

gynaecological,  265. 
Ophthalmia  neonatorum,  298. 
Osmosis,  65. 
Oxaena,  307. 


396 


A  TEXT-BOOK  OP  NURSING 


Pain,  121. 

Paralysis,  320. 

Passive  motion,  87. 

Pediculi,  320. 

Perforation  of  bowel,  328. 

Peristaltic  motions,  101. 

Peritonitis,  314. 

Perspiration,  116. 

Phlegm asi a  dolens,  286. 

Phthisis,  311. 

Pillows,  37. 

Placenta,  280. 

Pleurisy,  309. 

Pneumonia,  310. 

Poisons,  365. 

Poison  vine,  eruption  of,  356. 

Poultices,  155. 

Pregnancy,  268. 

Protrusion  of  bowel,  300. 

Puerperal  fever,  286. 

mania,  288. 

state,  272,  283. 
Pulse,  52. 
Pus,  238. 
Pyaemia,  252. 

Kachitis,  305. 
Recipes,  182. 
Respiration,  62. 

artificial,  360. 

Cheyne-Stokes,  114. 
Rheumatism,  334. 

Scabies,  319. 
Scalds,  236,  356. 
Sepsis,  241. 
Septicaemia,  253. 
Sheets,  31. 

to  change,  35. 
Shock,  251,  336. 
Sick-room,  model,  14. 
Sims's  position,  261. 
Sitz  bath,  83. 

Skin,   appearance   of,   in   dis- 
ease, 116. 

construction    and    function 
of,  75. 

diseases  of,  318. 
Skin-grafting,  237. 
Sleep,  375. 


Slings,  219. 
Small-pox,  331. 
Specula,  262. 
Spica,  210. 
Splinters,  355. 
Splints,  201. 

temporary,   351. 
Sponge  bath,  82. 
Sponges,  245. 
Sprains,  353. 
Sputa,  114. 
Stains,  to  remove,  33. 
Sterilizing,  181. 
Stimulants,    in    collapse,    252 

in  fever,  334. 
Stools,  120. 

to  disinfect,  230. 
Strangulation,  360. 
Strapping,  221. 
Stupes,  159. 
Styptics,  345. 
Suckling,  281. 
Sunstroke,  361. 
Suppositories,  107. 
Suppression  of  urine,  96. 
Surgical  cases,  234. 
Sutures,  244. 
Symbols,  138. 
Symptoms,  111. 

in  children,  295. 
Syringe,  care  of,  127. 

hypodermic,  127. 

Tampons,  262,  350. 
Taste,  disordered,  118. 

to  disguise  disagreeable,  131. 
T-bandage,  217. 
Teeth,  care  of,  77. 

development  of,  295. 
Temperature,  bodily,  54. 

of  baths,  78. 

of  room,  73. 

post-mortem,  376. 
Terminations  of  disease,  371. 
Tetanus,  253. 
Thermometers,  58. 
Thirst,  177. 
Thrombosis,  45. 
Thrush,  298. 
Tidal  air,  64. 
Tongue  in  disease,  77. 


INDEX 


397 


Tourniquet,  343. 
Typhlitis,  314. 
Typhoid  fever,  327. 
Typhus  fever,  329. 

Urine,  90. 
Urticaria,  318. 
Uterine  examinations,  261. 
in  labor,  275. 

Vaccination,  332. 
Veins,  49. 

varicose,  347. 
Ventilation,  69. 
Vermin  exterminator,  29. 
Visitors,  373. 
Vital  signs,  114. 


Vocabulary,  379. 
Vomiting,    119. 
to  control,  256. 

Ward  work,  20. 
Water,    cold,    externally,    79, 
161. 

internally,  177. 

Water,    hot,    externally,    161, 
347. 

internally,  79,  257. 
Water-bed,  38. 
Weights,  136. 
Whooping-cough,  302. 
Worms,  300. 
Wounds,  234,  354. 

poisoned,  355. 


(5) 


THE  END 


This  book  is  DUE  on  the  last  date  stamped  below 


JAN  2  6  1952 


Form  L-9-15wi-ll,'S7 


001429931    7 


of  CALIFORNi/ 
AT 

T.OS  ANGELES 
TJBRARY 


